In Kosrae, an island in Micronesia, new arrivals are a curiosity, and it seemed that half the island had come to greet me and Steven Auerbach, a Manhattan-based medical epidemiologist and an officer in the U.S. Public Health Service who had worked in Micronesia in the early 1990s, when we visited last year. Dazed from our 8,000-mile journey, we groped our way down the pockmarked coastal road, driving past groves of trees bent nearly double under loads of bananas, papayas, and breadfruit. We were on our way to a funeral feast.
We arrived to find the feast in full swing. Young men in lawn chairs played cards, while toddlers squatted, transfixed, around a television screen blaring taped cartoons. Hovering women filled plates and wiped faces. Perhaps a hundred people were there, and the dead man's wife looked bored. The deceased, buried four weeks earlier in a nearby crypt, seemed almost beside the point.
Kosraeans die young (the man in the crypt was fifty-six), but not for reasons commonly associated with the developing world. There is no famine here, and with the notable exception of upper-respiratory infections, little evidence of the diseases that cut life short in, for example, sub-Saharan Africa. The big killer in Kosrae—what some epidemiologists call New World syndrome—is a constellation of maladies brought on not by microbes or parasites but by the assault of rapid Westernization on traditional cultures. Diabetes, heart disease, and high blood pressure—scourges of affluence that long ago eclipsed infectious diseases as killers in the West—have only recently appeared here.
We sat with the dead man's brother-in-law, who told us that he expects to die soon too. His sister's husband died of heart disease; he himself will likely die of diabetes. "But I am fifty-seven, an old man, so this is of no matter," he said. He worried more about the young people. Nodding toward the cardplayers nearby, he said that it was not uncommon for them to gather to mourn a man or woman of thirty.
Kosrae was at one time a mighty kingdom, with Lelu its capital. Today Lelu is still the state's largest and most densely populated village, a jumble of tin-roofed huts connected to Kosrae proper by a causeway. We went to Lelu to see the ruins of the ancient city, built 600 years ago of immense basalt "logs." Exhausted by the heat, we ducked into a nearby general store to get a cold drink. Inside we found row after row of canned goods: Spam and corned beef and Vienna sausages in fancy tins. There were cake and muffin mixes from the United States, ramen-noodle soup from the Philippines, flats of soda and Budweiser beer, shelves of candy bars and potato chips. An entire freezer was reserved for turkey tails—a fatty, gristly hunk of the bird which is generally regarded as inedible in the United States. The freezer was empty. Turkey tails are so popular, we were told, that the month's shipment was long gone.
In the handful of other grocery stores scattered around the island we found plenty of salty, sweet, and fatty imports—but no fresh bananas, papayas, breadfruit, coconut, or mangoes. Apart from a fish shack or two and a few forlorn stands hawking bags of the island's famous—and costly—green tangerines, there was nowhere to buy local produce on the island. We were told that most Kosraeans once grew fruits and vegetables on family plots, and pulled tuna and reef fish from the sea. But the majority of modern Kosraeans don't have time or energy to farm or fish—they are too busy with their office jobs.
Kosrae is the smallest of four island states that make up the Federated States of Micronesia (FSM), the largest and most populous political entity to emerge from the Trust Territory of the Pacific Islands, which placed the islands under U.S. administration after World War II. In 1986 Micronesia implemented a Compact of Free Association with the United States, which dissolved its trust status. In order to sustain a security partnership, the United States is still the FSM's chief benefactor, supplying the bulk of its revenue—about $100 million—in aid each year. The bureaucracy required to manage and distribute this windfall continues to be Kosrae's single largest employer. Few if any of its jobs demand the skill or physical effort required by the traditional work of fishing and farming. Physical exertion has been further discouraged by expansion of the coastal road and the steady importation of cars, some bought with the help of government money. To walk in Kosrae is to announce that one is too poor to ride, and Kosraeans offer a lift to every casual stroller.
This newfound convenience comes at a high price, as a visit to Kosrae's state hospital revealed. A low-slung concrete structure with greasy windows and no air-conditioning, it is poorly equipped to handle anything but basic health needs. Patients with serious problems are airlifted to Guam or the Philippines. The hospital director, a former Vice President of Micronesia, confessed to us that he and his wife travel abroad for even routine checkups.
The hospital's inpatient ward has perhaps two dozen beds, and nineteen were occupied on the morning we visited. Thirteen people were there for complications of diet-related diabetes and two for heart conditions. Paul Skilling, a Kosraean family doctor, lamented that cases of diabetes, hypertension, and heart disease are as common as coconuts on his island. Another doctor half joked that even health-care professionals are at risk. "Look at me," he said, pointing to his paunch. "I am myself obese. My body-mass index is thirty-two. How long before I have these diseases?"
The doctor was indeed obese, but his body-mass index was only slightly higher than average for a Kosraean adult. In 1993-1994 the Micronesian Department of Health, with funding from the U.S. Centers for Disease Control, screened almost all the adults on the island and found that nearly 85 percent of those aged forty-five to sixty-four were obese. Non-insulin-dependent diabetes mellitus, heart disease, and hypertension are closely linked to obesity, so it is perhaps not surprising that more than a quarter of Kosraeans in this age group were also diabetic, and more than a third suffered from high blood pressure. (Non-insulin-dependent diabetes mellitus, or NIDDM, the kind that afflicts Micronesia, is also known as Type II or adult-onset diabetes; "diabetes" here refers to this type.) Vita Skilling, the island's chief of preventive health services, told us that efforts to reverse this trend have been disappointing. "Here you buy imported food in the store to show that you have money," she said. "Even if you don't have much money, you can buy turkey tails."
In Kosrae 90 percent of adult surgical admissions are linked to diabetes, and of these many are for amputations necessitated by vascular breakdown. There are more cases of renal failure than the hospital can handle, and cardiovascular disease is pervasive. And in Kosrae ill health hits early—frequently men and women have a first heart attack in their late twenties.
New World syndrome has taken hold throughout much of the South Pacific. The problem in Kosrae pales by comparison with that in the Republic of Nauru, a tiny, crowded island known as the Kuwait of the South Pacific. Nauru's citizens grew rich from the mining of phosphate deposits, which long ago eclipsed fishing as the state's major revenue source and are now nearly depleted. This rocky island's few patches of arable land were laid waste years ago by mining, so Nauruans subsist almost entirely on imports. Prosperity has brought them Japanese televisions, German luxury sedans, and Australian filet mignon. It has also brought them what Auerbach calls "the worst of 1950s American cuisine"—processed foods with plenty of fat, salt, sugar, and refined starches. As a result Nauruans have among the highest rates of obesity and diabetes on the planet, and a life expectancy of only fifty-five. In contrast, the region's poorest nation—Kiribati, thirty-three islands that straddle the Equator, with little money for imported food or anything else—has in its rural regions the lowest rates of noncommunicable disease in the South Pacific.