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| Journal of the New Zealand Medical Association,
29-April-2011, Vol 124 No 1333
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Communicable and non-communicable diseases in the
Solomon Islands villages during recovery from a massive earthquake in April
2007
Takuro Furusawa, Hana Furusawa, Ricky Eddie, Makiva Tuni,
Freda Pitakaka, Shankar Aswani
In the Solomon Islands, there was little clinical evidence
of non-communicable diseases (NCDs) until the
1960s,1 but research conducted in the 1980s
revealed that a substantial portion of adults were classified as suffering from
obesity, diabetes or hypertension.2 On the
other hand, mortality and morbidity by malaria, respiratory infections,
diarrhoea and other infectious diseases, which had once been the main causes of
deaths, have decreased due to improved hygienic conditions and health
services.3,4
In 2002, deaths due to communicable, maternal, perinatal and
nutritional conditions were 254.8 per 100,000 population, while those due to
NCDs were 363.9.5 Thus, although people are
still under the double burden of both types of etiological diseases, the
epidemiological transition has already been shifted toward higher prevalence of
NCDs.
On 2 April 2007, at 7:40 local time, a massive earthquake
(Richter magnitude 8.1), the epicentre of which was 10 km deep and 45 km
south-southeast of Gizo (the provincial capital of the Western Province), struck
the country (Figure 1).6,7
This earthquake and the related tsunami and landslides
killed 52 people, wrecked 3150 houses and left behind an affected population of
24,059 in the Western and Choiseul Provinces.8
The greatest damage was inflicted upon the residents of the town and
neighbouring semi-urban villages in Gizo Island, followed by coastal fishermen
and horticulturalists on several small islands.
In the devastated areas, people took refuge on mountain
ridges, since houses and infrastructure, including water supply, hygiene and
subsistence tools (e.g. fishing canoes and agricultural tools) were severely
affected.9
National, international and non-governmental efforts
delivered relief goods and sufficient food, and tried to control disease
incidences.8,10–12 While these efforts
were successful in avoiding severe outbreaks of infectious diseases and shortage
of food and drinking water, disease risks and dietary shortage remained an issue
at the local level.
In addition, during this time, the population experienced a
lifestyle change; some of the residents became increasingly dependent on
imported foods and cash economy because subsistence economy and local food
production were interrupted. Therefore, this disaster could potentially be
related to risks of communicable and nutritional conditions as well as
NCDs.
Figure 1. Locations of epicentre and study
villages in the Western Province, Solomon Islands
 This study aimed to explore the type of health and
nutritional problems that were likely to be prevalent during the recovery
process from the 2007 earthquake in the Solomon Islands. Special attention was
paid upon the effects of levels of damages, recovery and urbanisation.
The research was conducted 2 years after the disaster. This
time period was ideal to assess medium-term influences, since the adverse
effects of the initial phase are usually treated by emergency relief operations.
The effects remaining after withdrawal of intensive operations were little
studied. A greater understanding of these effects is necessary for implementing
or assessing long-term recovery action plans at the grass-root level.
MethodsStudy area—Out of 53 deaths
caused by the disaster, 33, including at least 29 Micronesians, occurred on Gizo
Island, followed by 11 on Simbo.
This study was conducted in August 2009 in the
following four villages (Figure 1; Table 1) in the Western Province. Titiana
village, where almost all houses were lost in the tsunami and all residents had
evacuated to the top of a hill and built a camp; both original settlement and
the camp were located at walking distances from the centre of the Gizo town
(approximately 45 minutes on foot).
During the study period, a portion of households had
returned to the original settlement, but the majority was still living in the
camp. Tapurai village, in the remote Simbo Island, had also been totally
destroyed by the tsunami. All residents, except only for a couple of households,
were living in a new settlement in Rupe, where subsistence gardens were located
before the disaster. Mondo village in Ranongga Island had lost about half of the
settlement due to landslides.
The majority of the residents moved into an inner
mountainous area and built a new settlement called Keigolo. Although this
village was geographically remote from the town, the lifestyle was manifestly
more modern than Tapurai, since it had been one of the biggest villages in the
island before the disaster, and even after the disaster, it had received
overseas aids for setting-up a clinic and rebuilding hygienic infrastructure.
Olive village in New Georgia Island was affected by the
quake but the sea level increased only slightly and did not change the
settlement.
Table 1 Characteristics of the study
villages
aSource:
The authors’ field observations; *At August 2009.
We therefore assumed that Titiana represented a village
severely damaged and located near the town, Tapurai represented a severely
damaged remote village, Mondo represented a severely damaged, medium urban
village and Olive represented a control village.
It should be noted that almost all residents in Titiana
were Micronesians who had migrated from the Gilbert Islands in
1960s,2 while those in the remaining three
villages were indigenous Melanesians.
Participants and interview
survey—In each village, all residents were invited to participate
in the study; measurements were made for three days in Titiana and two days in
Tapurai, Mondo and Olive. All participants who, based on their free will, agreed
and provided informed consent were included in the study; the consent was
obtained from a parent or a legal guardian in case of children less than 18
years of age.
This study has been conducted in full accordance with
the ethical principles of the World Medical Association Declaration of Helsinki
(as amended by the 59th General Assembly in Seoul, 2008) and was approved by the
University of Tokyo Ethics Committee, Japan, and the Solomon Islands National
Health Research Ethics Committee.
Every participant, or a parent or legal guardian in
case of children, was asked to report the date of birth, settlement place and
housing type; birth records were referred to in case of children to calculate
their exact age in months. Every adult was asked to report on his/her lifestyle
by replying yes or no in the questionnaire.
Health check-ups—Body height was
measured to the nearest 1 mm using a field anthropometer (TTM, Japan) and weight
was recorded to the nearest 0.1 kg using a portable digital scale (Tanita model
HD-654, Japan) according to a standard
protocol.13
Height was measured only for participants of 5 years of
age or older. Blood pressure of participants aged 18 years or older was measured
using a blood pressure monitor (HEM-7051-HP, Omron, Japan); readings were
obtained twice for every participant and averaged.
For malaria active case detection, thick and thin blood
films were collected by the finger prick method. All slides were taken to the
Malaria Department of the National Gizo Hospital to be examined under a
microscope; each slide was checked by at least two technicians. Malaria
detection was also made with a rapid detection test using the ICT Malaria Combo
Cassette Test (ICT Diagnostics, South Africa) on site.
The blood obtained from the finger prick method was
also used to measure haemoglobin A1c (HbA1c) and C-reactive protein (CRP) using
NycoCard HbA1c (Axis Shield, Norway) and NycoCard CRP tests, respectively, and
read using a NycoCard Reader II on site. HbA1c is a glycated haemoglobin that
reflects plasma glucose concentration over the past two to three months and is
an indicator of diabetes mellitus.14-16 CRP is
a component of acute innate immunity that increases in concentration in response
to a range of pathogenic agents and
inflammation.17,18
Statistical analyses—The health
indicators measured in this study were conceptually classified into (i)
communicable and nutritional conditions and (ii) NCDs. Indicators for
communicable and nutritional conditions included malaria infection (positive or
negative), adult malnutrition (BMI < 18.5
kg/m2), adult and child infection status (CRP
≥ 1.0 mg/dL),18 child stunting
(height-for-age z-score (HAZ) < −2), child underweight
(weight-for-age z-score (WAZ) < −2) and child malnutrition
(BMI-for-age z-score (BMIZ) < −2). Those for NCDs included
adult overweight (BMI ≥ 25 kg/m2),
obesity (BMI ≥ 30
kg/m2),19
hypertension (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg) and diabetes
(HbA1c ≥ 6.5%).16
Standardisation of measures (i.e. z-score
calculation) for children was performed based on the CDC/WHO 1978 growth curves
recommended by the WHO using Epi Info version 3.5 software (Centers for Disease
Control and Prevention, Atlanta, USA). Associations between the villages and the
health or life level indicators were tested using Fisher’s exact test.
Multiple logistic regression analyses were performed to
detect the effects of villages, individual-level settlement and housing styles,
age and gender on the health indicators; settlement was treated as an
environmental factor, while ownership and style of housing as factors of
socioeconomic status. In this study, a P value of less than 0.05 was
considered to be statistically significant. All statistical analyses were
performed using SAS 9.2 (SAS Institute, Cary, USA).
ResultsAlmost all participants from Tapurai and Mondo villages
lived in settlements that were established after the disaster (Table 2); the
majority of Titiana participants lived in a camp, but the remaining had returned
to the old settlement. As opposed to 16.4% of participants from Titiana, only
6.7% and 2.9% of participants from Tapurai and Mondo, respectively, still lived
in tents or temporary houses.
Regarding subsistence activities, almost all households were
engaged in horticulture (making traditional gardens) in Tapurai, Mondo and Olive
villages compared to only 75.4% of the peri-urban Titiana village households.
The proportion of Mondo households engaged in fishing was as low as that of
households in the urban Titiana. The proportion of households having a running
business and employment or remittance for cash income was high in Titiana and
Olive.
Table 2. Socioeconomic status of the
participant households
Regarding health indicators, microscopy analyses of blood
films found only one Plasmodium vivax-positive case (Table 3). Malaria
rapid detection test also rarely found positive cases: two P.
falciparum cases and six P. vivax cases. In addition, adult
malnutrition was very rare (ranged 0–2.5%) (Table 3).
Infection or inflammation condition measured by CRP was
found in higher proportion in Titiana and Tapurai than in Mondo and Olive
(Fisher’s exact test P = 0.0179). The prevalence was high among
participants younger than 18 years old; the prevalence was 14.6% and 9.5% in
Tapurai and Titiana, respectively, and only 2.7% and 5.8% in Mondo and Olive,
respectively (N.S.). The proportion of children with low height-for-age
z-score was the highest in Tapurai, followed by Mondo, Olive and
Titiana (P < 0.0001). Children with low weight-for-age z-score were
less frequent in Titiana than in the other three villages without significant
inter-village differences. Regardless of the prevalence of low body height
and/or weight, low BMI-for-age z-score was rare (0%–5.8%).
Table 3. Prevalence of communicable and
nutrition diseases and non-communicable diseases (the number of participants
examined are in parentheses)
aPv: Plasmodium
vivax, Pf: P. falciparum
* P < 0.05
***P < 0.0001.
Also, as shown in Table 3, the prevalence of overweight
adults was high with a large inter-village variation; the prevalence was highest
in Titiana (62.5%), followed by Mondo (51.7%), Tapurai (39.7%) and Olive (23.7%)
(P < 0.0001). Obesity with BMI ≥ 30
kg/m2 was also most frequently found in Titiana
(P < 0.0001). Hypertension was most prevalent in Mondo, followed by
Titiana, Olive and Tapurai (P < 0.0001). Diabetes was found in 8.9%
of Titiana population, but was seldom observed in other villages (0%–1.7%)
(P = 0.0156).
Multiple logistic regression analyses were performed to
identify the effects of villages and life-related factors on these health
indicators (Table 4). Infectious or inflammation
conditions were more prevalent in Titiana and Tapurai, whereas they were
referenced as minimum damage in Olive village; children in Tapurai were also
referenced at risk. At the individual level, younger participants and children
who lived in the old settlement were at risk.
Tapurai children were likely to have low height for a given
age. Adults in Titiana and Mondo villages were at risk for being overweight, but
obesity was found only in Titiana and not in Mondo. Hypertension was more
prevalent among the older residents and female gender; Mondo village was not at
risk when these risk factors were controlled. House ownership and housing style
were not related with NCDs.
It should be noted that no significant model was found when
adult malnutrition, child low body weight and adult diabetes were used as
dependent variables due to small numbers of positive cases.
As shown in Table 5, a majority of residents
(63.8%–78.7%) complained about their cash income. Compared to the Titiana
and Mondo residents, the majority of Olive and Tapurai residents were satisfied
with productions from horticulture (88.1% and 94.2%, respectively) and fishing
(94.9% and 94.2%) (P < 0.0001).
Table 5. Adult participants’ perceptions
of their standard of living
***: Fisher’s
exact test P < 0.0001
DiscussionThis study examined the prevalence and risks of communicable
diseases and NCDs in Solomon Islands villages where fishermen and
horticulturists as well as urban dwellers experienced environmental changes,
i.e. a massive earthquake, and related socioeconomic changes. This is also one
of the few studies which report NCD prevalence in rural Melanesian societies.
A limitation of this study was that our data were available
only for cross sectional analysis, and thus, the direct effects of disaster and
relevant effects of the recovery could not be distinguished from the progress of
socioeconomic conditions. However, the inter-village differences found in this
study are adequate to interpret ecological and socioeconomic effects related to
the disaster and urbanisation.
Since previous studies from Melanesia have suggested that
obesity, hypertension and diabetes were increasing in urban
areas,2,20-22 it is likely that the urbanised
lifestyle in Titiana is related with the high prevalence of obesity and
diabetes; although there was a potential confounding factor that Titiana people
had a different ethnicity (Micronesian) from other three villages.
High prevalence of overweight people in Mondo was thought to
reflect a progress of urbanisation in remote areas; Mondo was more affected by
modernisation than Tapurai and Olive before the disaster and had received more
aid. Another potential factor was that they were not frequently engaged in
fishing since they were now settled in inner and mountainous area; this
lifestyle might have decreased their physical activities and energy expenditure.
From the viewpoint of other life factors, Tapurai and Olive
residents had sufficient local food production (garden crops and fishes), while
Titiana and Mondo residents did not. It is interesting to note that NCD
prevalence was low in the former two villages, suggesting that lifestyles with
sufficient local production, subsistence and physical activities could have
decreased NCD risks. This suggestion is partly supported by a previous finding
that abundance and availability of natural resources, e.g. fishes, were directly
related with health status in this area.23
From the longitudinal viewpoint, our previous study reported
that obesity (BMI ≥ 30 kg/m2) prevalence
was 2.4%, 18.6% and 30.1% in rural Melanesian, urban Melanesian and peri-urban
Micronesian villages, respectively, in 2004 in the Western
Province.24 The obesity prevalence was 10.0%
and 10.3% in Mondo and Tapurai, respectively, suggesting that the risk for rural
residents might have gradually increased.
Child body weight is an indicator for short-term sufficiency
of food, while child body height (e.g. stunting) reflects a chronic effect of
nutrition and infectious conditions. Since body height of Tapurai children was
lower than that of children from other villages, although body weight did not
differ, it is possible that children in Tapurai might have experienced chronic
malnutrition or infectious risks.
Since Tapurai residents, especially children, had high CRP
values, while they admitted that they had sufficient subsistence production, it
is reasonable to hypothesise that they were living under a risk of chronic
infection by pathogens. Note that although a chronic ulceration secondary to
diabetes is a possible confounding factor to the increased CRP value, diabetes
prevalence was quite low in the study villages.
Health statistics have suggested that malaria prevalence in
the Western Province had decreased from a peak of 506 patients per 1,000
population per year in 1994 to 58 patients in 2005; although a mass
administrative survey was conducted soon after the disaster in 2007, only 78.5
patients per 1000 population were found to be positive for malaria (Malaria
Department, National Gizo Hospital, personal communication). However, our
results suggested that even if outbreaks of malaria and other major infectious
diseases were avoided, minor infectious risks remained in some rural villages.
Interestingly, Titiana residents who bear the risks of NCDs
also bear risk factors of infectious conditions. Epidemiological transition
theory have usually assumed that NCDs increase as urbanisation progresses while
replacing infectious diseases,25 but our
findings suggest that urban people experienced both kinds of diseases. In fact,
a previous study reported that 12 out of 14 drinking water samples from Titiana
were contaminated with E. coli.9 Thus,
public health concern should be focused on in urban areas as well.
The data demonstrating that children living in households in
the new settlements had a lower risk of having a high CRP value is thought to
reflect a delay in constructing improved hygienic living conditions in old
settlements.
Previous public health research on the disaster have
suggested that large natural disasters are usually followed by increased
incidences of complex injuries and outbreaks of infectious diseases in victims
within a short-term period.26-28 Therefore,
priority has been given to the prevention of health
disaster.29
In the case of the Western Solomon Islands, appropriate
relief and aids were successful enough to interrupt the infectious outbreaks in
the initial stage of the disaster. However, public health risks remained after
two years.
On the other hand, NCDs have been reported to be increasing
in the Pacific societies,30 and were found at a
high frequency in the devastated areas. Controlling the NCDs during recovery
operations will efficiently improve the health status.
Since massive earthquakes continue to occur in the
Pacific—e.g. 1998 Papua New Guinea Earthquake; 2009 Samoa Earthquake and
Tsunami; January 2010 M7.2 and M6.9 Earthquakes in the Western Solomon Islands;
2010/2011 M7.1 and M6.3 Earthquakes in Canterbury, New Zealand; and March 2011
M9.0 Tōhoku Earthquake and Tsunami in Japan—the data reported in this
study will be useful for implementing appropriate recovery actions.
Recommendations resulting from this study are
Competing
interests: None.
Author information: Takuro Furusawa,
Associate Professor, Graduate School of Asian and African Area Studies, Kyoto
University, Kyoto, Japan; Hana Furusawa, Assistant Professor, Department of
Human Ecology, Graduate School of Medicine, The University of Tokyo, Tokyo,
Japan; Ricky Eddie, Chief Laboratory Officer, Gizo Hospital, Gizo, The Solomon
Islands; Makiva Tuni, Deputy Director, Department of Health Promotion, Ministry
of Health and Medical Services, Honiara, The Solomon Islands; Freda Pitakaka,
Chief Research Officer, National Health Training and Research Institute,
Ministry of Health and Medical Services, Honiara, The Solomon Islands; Shankar
Aswani, Associate Professor, Department of Anthropology, University of
California, Santa Barbara, California, USA
Acknowledgements: The Ministry of
Education, Culture, Sports, Science and Technology (MEXT) of Japan (KAKENHI
Grant-in-Aid) and United States National Science Foundation (NSF) financially
supported this study. We are also grateful to the staff members of the Ministry
of Health and Medical Services of the Solomon Islands, in particular Ms
Josephine Watoto and Ms Connie Panisi. Lastly our sincere thanks to all the
people of the villages studied.
Correspondence: Takuro Furusawa, Associate
Professor, Graduate School of Asian and African Area Studies, Kyoto University,
Yoshida-Honmachi, Sakyo-ku, Kyoto 606-8501, Japan. Fax: +81 (0)75 7537834;
email: furusawa@asafas.kyoto-u.ac.jp
and Shankar Aswani , Associate Professor, Department of Anthropology, University
of California, Santa Barbara, CA 93106-3210, USA. Email: aswani@anth.ucsb.edu
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