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.
Scientists have studied the health status of native peoples in the South Pacific for decades, and have noted the explosion of diet-related disease in Nauru and Micronesia, among other islands. But the CDC-supported effort seven years ago was the first to offer systematic health screening of adults in the islands of the FSM. Auerbach was in charge of that screening. He told me that it had made possible the early identification and treatment of health problems, and had helped to alert the islanders to the perils and prevention of noncommunicable illnesses. Among the small victories were an early-morning walking program for adult women and the Micronesian One Diet Fits All Today campaign, through which Kosraeans are encouraged to avoid imported food in favor of locally grown fruits, vegetables, tubers, and fish. Vita Skilling said that although MODFAT had helped some patients to reduce their blood pressure and dependence on diabetes medication, she did not know whether the program had had a wide impact. She invited us to attend a party for a group of women who had recently "graduated" from the MODFAT program. We arrived in time for lunch and were offered fresh fish, breadfruit, fried chicken, orange soda, candy, and apple pie. Most of the graduates were hugely obese. Apparently the "healthy diet" message had gotten muddled. The walking program, although enthusiastically endorsed by the clinicians I spoke to, was in May still suspended "for the Christmas holiday."
Paul Zimmet, an Australian physician and researcher who specializes in the study of noncommunicable diseases, wrote in 1996 that "the [non-insulin-dependent diabetes mellitus] global epidemic is just the tip of a massive social problem now facing developing countries." Zimmet implicated the "coca-colonization" that has devastated local customs and economies and led to ill health. Rates of obesity and diabetes have skyrocketed around the globe, but particularly among traditional peoples in transition—Polynesians, Native Americans, and aboriginal Australians; Asian Indian emigrants to Fiji, South Africa, and Britain; and Chinese emigrants to Singapore, Taiwan, and Hong Kong.
Although the rapid introduction of processed foods and other conveniences is certainly the proximate force behind this trend, scientists are also looking at genetic components. Jeffrey Friedman, a professor and the head of the Laboratory of Molecular Genetics at the Howard Hughes Medical Institute at Rockefeller University, in New York, is investigating why some Kosraeans manage to escape the hazards of coca-colonization while others succumb. To Friedman and his team, the interesting question is not why so many sedentary, office-bound, Spam-loving Kosraeans are obese but why not all of them are.
Kosraeans, like all natives of Micronesia, trace their ancestry back 2,000 years to a handful of Indo-Malayan mariners. Driven by fear, religious persecution, greed, or foolhardiness, this small band settled the Pacific. Those who landed on Kosrae developed a feudal society that went largely unnoticed by the West until 1824, when a French research vessel, the Coquille, dropped anchor nearby. Rene Primevere Lesson, the ship's doctor, described Kosraeans as "advanced people of a high civilization, to judge from the vestiges of customs, tradition such as the authority of the chiefs, classes of society, and the remnants of the arts which they still practice." The women, he wrote, had "black eyes full of fire and a mouth full of superb teeth but a tendency to become fat." He also observed that considering the island's bounty, its population of about 3,000 was surprisingly small. (Easter Island, in Polynesia, was then supporting a population of at least 7,000 with roughly the same land mass and a less hospitable climate.) Studies later supported local lore that a much larger population had been diminished by starvation after typhoons devastated the island's food supply. The population continued to dwindle throughout the nineteenth century, as Kosrae became an increasingly popular base for pirates and New England whalers, who brought with them tobacco and whisky—and infectious diseases. By 1910 only 300 Kosraeans had survived the Western imports of smallpox, measles, influenza, and sexually transmitted diseases.
James Neel, a geneticist at the University of Michigan Medical School who died last year, hypothesized in a 1962 article on diabetes that under conditions of scarcity natural selection weeds out people unable to store food efficiently in their bodies, and that a "thrifty genotype" encourages the conversion of calories into body fat. He suggested that this mechanism was necessary for survival during periods of extreme stress and famine that would otherwise ravage a population. Most populations are assumed to have some variation on this genotype, but it is likely that peoples whose evolution was punctuated by a number of particularly harrowing events developed the most-effective versions. In Kosrae, where weather and disease wiped out 90 percent of the population, this effect must have been profound. The very genes presumed to have protected islanders from their history are now believed to be predisposing them to life-threatening illnesses.
In 1994 Friedman and his team at Rockefeller cloned what is perhaps the ultimate thrifty gene—the obese gene, which in its normal form carries the chemical code for leptin. A hormone discovered by Friedman, leptin plays a critical role in the brain, regulating appetite and fat storage, among other things. Leptin is an extremely potent hormone. People who carry the abnormal form of the obese gene don't have the genetic makeup to produce leptin; they eat uncontrollably and are morbidly obese. Although very few people have this defect, all of us have variations along the leptin and perhaps other brain pathways that influence our eating habits and efficiency at turning calories into body fat. Friedman's group examined blood samples taken from 2,286 adult Kosraeans in the course of Auerbach's islandwide screening. Preliminary findings suggest that European genes inherited from New England whalers and other visitors protect Kosraeans to some degree against obesity and diabetes: the more "European" an islander, it appears, the less likely he or she is to be obese or diabetic. Zimmet says this finding is consistent with earlier findings linking Asian genes with those of populations from Native Americans to New Guinea highlanders. Scientists speculate that certain aspects of the Asian genotype, evolved in part to withstand long periods of scarcity, predispose hundreds of millions if not billions of people to obesity and diabetes.
Writing in Nature in 1992, Jared Diamond, a professor of physiology at the UCLA Medical School, suggested that the populations of Western industrial nations had already to some extent weeded out the thrifty genotype, keeping diabetes and obesity below the levels now common in Micronesia. "Before modern medicine made [diabetes] more manageable," he wrote, "genetically susceptible Europeans would have been gradually eliminated, bringing [diabetes] to its present [relatively] low frequency." Diamond and others have suggested that some human populations, notably those that evolved in regions of Europe, may have developed a relative resistance to certain noncommunicable diseases just as they did to some infectious diseases—through natural selection over centuries of relatively sustained plenty. Given the burgeoning rates of obesity and diabetes in the United States and other industrialized nations, this seems surprising, until one considers that rates among the most susceptible peoples—Pacific Islanders such as Native Hawaiians, Samoans, and Nauruans—are higher still. Indeed, all measures indicate that the greatest impact of obesity-related disorders will continue to be in newly industrialized and developing nations in Asia, Africa, the Caribbean, Latin America, and the Indian and Pacific Oceans which historically had an unstable food supply.
The World Health Organization recently described overeating as the "fastest growing form of malnourishment" in the world. For the first time in history the number of people worldwide who are both overweight and malnourished, estimated at 1.1 billion, equals the number who are underweight and malnourished. Obesity rates in China have quadrupled in the past decade, and obesity in the urban middle class in India is epidemic. In Colombia 41 percent of adults are overweight. The global spread of diet-linked disease presents one of the greatest medical challenges of the twenty-first century.
But when I spoke with agricultural and business leaders in Micronesia, it was clear that a concerted government effort to fight noncommunicable disease was not likely on these islands. I heard repeatedly that health was a matter of willpower and individual effort, and that government could do nothing to curb the public taste for imports. The fact that many state legislators in Micronesia are also food importers was never mentioned—nor were the particulars of auto importation in a tiny country already overrun with cars.
Father Francis Hezel, a Jesuit priest from Buffalo, New York, who has spent more than three decades teaching and writing in Micronesia, said that even people in power are reluctant to speak out. "You can enter any clinic and smell the decaying limbs, rotted by diabetes," he told me. "But many people here are beholden to the government. They don't want to rock the boat." In Micronesia—as in much of the world, particularly the developing world—it is more profitable for authorities to encourage overconsumption than to discourage it. The Worldwatch Institute reported last year that approximately four of the five McDonald's restaurants that opened every day in 1997 were outside the United States. In its 1998 annual report the Coca-Cola Company described Africa as "a land of opportunity."
Obesity, diabetes, and other manifestations of New World syndrome can, like infectious diseases, be contained. In Singapore the nationwide Trim and Fit Scheme, which began in 1992, has cut childhood obesity by up to 50 percent. And in Hawaii, Terry Shintani and colleagues at the Waianae Coast Comprehensive Health Center have shown long-term health benefits from a program emphasizing a return to traditional local foods.
We spotted a glimmer of progress in Micronesia, though not in the Western-style wellness programs. One of our hosts, a hospital administrator, told us that he neither farmed nor fished but did enjoy playing basketball, and that he would sometimes jog rather than drive to the high school gym to play. As a result of this regimen he had lost a significant amount of weight, and avoided some of the health problems suffered by his more sedentary compatriots. Basketball, he said, was catching on quickly in Kosrae, as was baseball. "Imports made us sick," he said. "Now maybe imports will help us get well."
However nice the thought, increasing amounts of junk food are being shipped into Kosrae from the West, food importers say, and the island is about to import television programming. Kosraeans will be able to come home, open a few cans of Spam, switch on the tube, and kick back for the evening. It is then that they will truly be able to live—and die—in the manner of their Western benefactors.