The Evolving Inter-Generational Health Trends of the Fijian Girmitya progeny

Abstract ???????

In the Girmit era (1879-1920), Fiji recorded the highest incidence of girmitya deaths of all the British sugar colonies (1). Underpinned possibly, with malnutrition, Communicable Diseases (CD), was the leading cause. Non-Communicable Disease (NCD) ranked lowly on the cause of death certification.

Post Girmit (1921), credible data analysis only became available from the 1960’s. This dataset demonstrates the insidious increase of NCD related morbidity and mortality into the 1980’s (2). The last two decades of the 20th Century, data analysis demonstrates a massive increase in Diabetes, and Cardiovascular Disease. In the 1st two decades of the 21st Century we face an explosion of NCD related premature deaths (3).

?On current “projectional trajectories” medical research forecast a future where a wider range of NCD complications eventuate. This is compounded by the health impacts of climate change, increasingly frequent and forceful adverse weather events and pandemics (4). An existential threat exists in the Pacific Small Island States (PSIDS) and Fiji specifically. Associated climate related changes and extreme weather disasters complicate the lifestyles of the already medically compromised Fijian Girmitya progeny. Improving health literacy strategies, addressing the commercial determinants of health and rebranding lifestyle modifications may hold the important keys to reversing increasing premature morbidity and mortality.

?Introduction

With the abolition of Slavery (1833), global demand for human labour escalated sharply, especially within the expanding British Empire. The unprecedented waves of migration of over 1.3 million Indian workers under the British Empire saw the arrival of 60,965 indentured laborers (girmitya) to the Fijian shore under the authority of Colonial Governors, starting with Arthur Gordon and continuing until 1920 (1,5,6).

This paper provides a narrative of the evolving intergenerational health trends of the Girmitya based on available data and review of scientific literature. Second, the paper reviews the current WHO projections in drawing up a forward strategy to contain the NCD crisis. Third, targeting the three areas of Health Literacy, Policy Review on Commercial Determinants of NCD and rebranding Behavioral Modifications are the “low hanging fruit” to easily arrest the upward spiraling NCD Crisis.

The Girmit Era (1879-1920)

Of the approximately 61,000 brought to Fiji, around 8,500 or 14%, perished from a variety of causes within the areas of acquired medical conditions, suicide, homicide and accidents (1,4,5). Most deaths were recorded early in their stay in Fiji. Fiji recorded the highest incidence of girmitya death within all British colonies (1,5).

A literature search on “Girmityas’ health” was undertaken in 2017 at the National Archives, Fiji. Late Professor Brij Lal’s data on health issues during the indentured period in Fiji was reviewed. ?Comparative data from the colonial secretary’s reports over the girmit era from published and unpublished sources were assessed for comparison. A “Fresh Eyes” approach with respect to the original morbidity/mortality dataset in light of modern medical diagnosis was then undertaken (7).

The analysis of the rations and caloric requirements for heavy tasking work were undertaken to determine whether inadequate calories provided led to a stage of chronic malnutrition using the Harris-Benedict Equation. This entailed having to calculate the daily minimum caloric requirements for indentured workers for the type of work they were required to do using newer scientific methodology. This demonstrated that there was at least a 24% shortfall in the caloric requirements for adult male workers in the indenture ration packs. Workers were provided these packs for 6 months on starting the indenture period.

The shortfall, together with lack of any provision of reasonable protein sources, are compelling factors in causing malnutrition. Given the massive shortfall in the minimum dietary requirements for the type of work being done on plantations, it is proposed that malnutrition on the plantations during indenture was a chronic factor(6).Further the Girmitiyas’ Health Review, 2017 analyzed the original morbidity/mortality dataset in light of modern medical diagnosis and gaps highlighted.

It is proposed that the causes of death listed in the official reports could not have been determined with any scientific levels of confidence. There is no documentation or record on the factors which the officials used, viz a viz a checklist, to identify the cause of death of a girmitya (7). Finally, the 2017 study proposed that chronic malnutrition in indentured workers could have been the underlying cause of most of the deaths, which were erroneously listed in official reports as resulting from a number of other causes (5). Compounded with other variables like poor sanitation, parasitic exposure, hard tasking labour, physical and mental torture, chronic malnutrition on Fijian plantations underpinned and consequently contributed to the highest morbidity and mortality rates within all of the Britain’s sugar colonies (5,7).

?The Post-Girmit Era (1921-1960)

The Secretary of Health’s Annual Reports remains of variable and limited scientific value in colonial times (4). Only in the 1960’s credible, comprehensive and ??formal medical research commenced. ?An insidious and gradual increasing number of NCD from the hospital reports were noted. (2,3) Drs. Sutton, Parshu Ram, Cassidy, Bakani and Salik Govind undertook pioneering work in data collection, analysis, reporting and publication in the medical literature. Their efforts resulted in health service reviews but marred with slow administrative policy directives within the healthcare system over the subsequent forty years (1960-2000). ?

The Evolving Pattern of Disease (1960-1980)

?A steady increase of NCD’s in the community was statistically noted. Diabetes mellitus and cardiovascular diseases being the focus of studies (3,4). The patterns of diabetic presentations were quite different in the two ethic communities although the disease centered around the 40-year age group, interestingly 40 years after the end of indenture era. In the girmitya progeny the classical presentation was followed by diabetic screening and diabetic sepsis undertaken, to reach a diagnosis. The “itaukei” (indigenous) community presented with diabetic sepsis as the lead symptom, followed by screening and classical symptoms of diabetes in the 3rd position. Type-one diabetes, coma and renal complications were rarely noted in the initial dataset. Gestational diabetes was rare (3%). ?

Ground breaking studies in the incidence of diabetic complications by Dr. Cassidy had taken place in 1964-65 noting the multi-organ impacts. Only 10% of diabetes was a stand-alone diagnosis. Other target organs for diabetes at that stage included cardiac, ocular and kidneys, in that order in the girmitya progeny. The Dr. Bakani 1964 study on the rising incidence of cardiac disease was the catalyst in the establishment of a two-bed coronary care unit at CWM hospital, Suva (8). The clinical load at the clinics were mounting and reflected in the hospital statistics with limited comprehensive workforce capabilities. Diabetes mellitus was red flagged in 1971 by the lead physicians at the three divisional hospitals.??????

On the recommendation of the World Health Organization (WHO) in 1980, initiatives to establish a custom-built national body to address NCD was proposed (9). After much sustained effort, The National Diabetic Foundations was established in 1984. Local protocols were developed following Australian institutional exposure provided to a doctor, two nurses and a dietitian. Professor Zimmet who had undertaken extensive epidemiological studies on NCD in 1980 in Sigatoka, Suva and the Lau group of islands was very supportive to this initiative. On the persistent efforts of Chief Clinician Dr. Parshu Ram, his professional colleagues from abroad and the local private sector saw the Foundation establish a strong foothold. These efforts were endorsed by the late Ratu KKT Mara, Prime Minister of Fiji (9).

The NCD Epidemic (1980-2000)

Two decades of the twentieth century 1980-2000 demonstrates the cataclysmic increase in both the incidence and prevalence of diabetes and cardiovascular NCD. Dr. Salik Govind reviewed the increasing incidence of cardiac diseases as co-morbidity to diabetes mellitus in the 1983-86 period, within the evolving clinical scenario. The increasing clinical workload, influx of inpatient care, increasing morbidity and mortality were of great concern to the leaders in the medical community. ?

Although the indigenous population had a much lower incidence of NCD-Diabetes mellitus previously, the incidence rapidly caught up and started presenting with NCD complications inclusive of cardiac presentations. The political events of 1987 (Coup d’ Etat) affected service delivery with a 33% loss of manpower in the doctor’s cadre and the whole NCD effort took a steep slippery slide to the end of the 20th century (8).

The Tsunamic of NCD (2001-2022)

The first two decades of the 21st century demonstrates a tsunamic rise in both incidence and prevalence of NCD in both the ethnic communities, no longer exclusive in the girmitya progeny. No longer a disease of the fourth decade of life, the evolving disease patterns and presentations continued to occur as individuals in their 20-30’s became symptomatic or suffered cardiac shock, rhythm disturbances and premature death. Presentations earlier in the second and third decades of life especially in the girmitya progeny with worsening co-morbidities and mortality was noted (3,8). ?

Projectional Forecasts (2020-2050)

On current projectional trajectories medical research forecast a problematic future where a wider range of NCD complications eventuate. Apart from stand-alone diabetes mellitus (10%) and cardiovascular diseases, the compounding complications by co-morbidities, cancers and mental health components continue to unmask insidiously. If meaningful early interventions to this NCD crisis are not mobilized early, the girmitya progeny face an existential dilemma. The health impacts of climate change, extreme weather events and forecasted future pandemics will impact strongly on an NCD compromised girmitya progeny and that of his itaukei brethren. ?

The trifecta of Health Literacy, Policy Review on Commercial Determinants of NCD and rebranding Behavioral Modification can become the practical foundation, in arresting the spiraling NCD Crisis.

1.???Health Literacy

General Literacy is classified as basic, functional and creative. Strangely, Fiji claims a general literacy of 99% based on four years of unsupervised attendance in primary school, without any caveats within its variable educational environment. Unfortunately, basic numeracy and literacy does not provide abilities to process practical health literacy. Consequently, the gap between comprehension and application of knowledge to health issues remain wide and deep (10,11).

The Health ministry’s Wellness Promotion unit and the Education ministry must reconcile this literacy gap and act, at all levels in the school system and in community educational programs. The onus remains to align the education system and health’s wellness policy directed programs (11). The absence of such alignment worsens health inequities in the communities. The need for such issues has been repeatedly spelt out and evident in even the more recent 2015 Yanuca Declaration voiced by Pacific leaders (12,13).?The target is to enhance true functional health literacy.

Reflections on addressing health literacy remains at the heart of health promotion in the 21st century.?Raising health literacy to address the worsening global health inequities remains urgent work in progress. Multisectoral approaches to identify the social determinants of health (SDoH) inclusive of commercial health determinants (CDoH) which reduce health inequities is not unscalable.

Currently the mis-match between comprehension level of health promotional material and instructional methods are set much higher to our populations general functional state of literacy. Innovative reorientation of healthcare policy and program delivery using the top-down and down-up approaches can address the current health promotion gaps. A new NCD policy direction needs to be considered, with focused programs which are monitored and evaluated, real-time to enhance health literacy (13,14).

?2.???Policy Review on Commercial Determinants of NCD

Commercial Determinants of Health (CDoH) is a new field of study and classification, within Social Determinants of Health (SDoH) covering three salient areas. First relates to unhealthy commodities that contribute to ill-health. Second, they include business, market and political practices that are harmful to health and are used to sell these commodities by securing a favorable policy environment. Finally, the inclusion of the global drivers of ill-health, such as market-driven economies and globalization, that have facilitated the use of such harmful practices (16,17).

There are four major areas of health interest in the CDoH. The consumption of Tobacco, Alcohol, ultra-processed Fast-Food and the Sweetened Sugary Beverages (SSB) industries; transnationally visible who contribute to significant NCD related ill-health. The impact is much more evident in the low resourced developing countries and more so in the Pacific Small Island States (18). Fiji is not an exception and our girmitya progeny along with the indigenous population, no longer an exception due to the evolved lifestyle and subject to premature onset NCD risk.

Following a 2009 Food and Agriculture Organization (FAO) Vanuatu Summit, Fiji’s Health Team decided to commence national level consultations with all parties dealing with Food, Drinks Alcohol, Tobacco industries. This initiative was supported by United Nations organizations, Bilateral partners and Civil Society organizations, in a wide and open arena. Areas of public awareness, Industry policy changes, government regulation, grading of food outlets, product reformulation, enforcement and taxation were tabled for discussed.

Great strides were made in policy drafting, law changes with increased taxation, new regulations, annual licensing and fees restructuring for stakeholders followed. Enforcement within the tobacco industry eventuated successfully. However, the SSB industry working outside the gambit of the larger group, sought political leverage for self-regulation to a limited number of like-minded transnational and national corporations. British Health Forum study (2018), specifically published a review on Fiji’s failed Self -Regulation Limitations (18)

More recently the Lancet in April of 2023 has projected the future role of the commercial sector in global health and health equity (19). The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can eradicate the harms from the commercial determinants of health-the business models, practices, and products of market actors that damage health equity and human and planetary health and wellbeing. Evidence shows that progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social, and environmental goals, and strategic civil society mobilization together offer possibilities of systemic, transformative change, reduce those harms arising from commercial forces, and foster human and planetary wellbeing (19).

Despite WHO having initiated a new programme of action, the Economic and Commercial Determinants of Health, with four goals: to strengthen the evidence base; develop tools and capacity to address the commercial determinants; convene partnerships and dialogue; and raise awareness and advocacy help is not being sought by Pacific Small Island States (17).

Within the Fijian jurisdiction the Wellness Policy has been in the draft stage for the last eight years. Dysfunctional policy development with the current program deficiencies and non-existing enforcement strategies are producing no programmatic gains. This remains a politically motivated strategy as State Capture stalls implementation of a forward plan. The SSB and the Fast food Industries are still the elephants in the room and continue to economically benefit whilst the health inequities reach a crisis tipping point (20).

3.???Behavioral Modification

The UN endorsed “Best Buy’s Strategy” of 2010, is in fact still a comprehensive targeted approach in addressing the NCD crisis globally. However cultural, traditional and country specific initiatives need to be factored in any rebranding exercise. Fiji’s draft Wellness Policy is an example when the lead organization has absolved itself of any responsibilities. Fiscal support is absent and monitoring & evaluation surely belong to the policy makers and program directors. The draft has not been endorsed in the last eight years and lacks direction. A major refocus is needed if the NCD crisis is to be gated.?

?As 80% of deaths are related to NCD currently it remains mandatory to prioritize Policy direction to addressing improving strategies to raise Health Literacy in schools, communities and nationally with awareness, legal input into laws, regulations and the enforcement of legislations. A major review of the social determinants, especially the Commercial Determinants of health needs to be addressed. Sandwiched between improving Health Literacy effort and Commercial Determinants of Health, one has Modification/ Rebranding the Best Buy’s strategies to contain NCD crisis. This remains an inter-generational health issue of global concern if society fails to make this effort.

Conclusion

The inter-generational health trends of the Fijian Girmitya and their progeny demonstrates the evolution of morbidity and mortality from communicable disease to non-communicable diseases over the last 144 years. Each decade has unfolded the evolution of a complicated mix of disease patterns with a problematic incidence and prevalence. The inter-twining of disease patterns with the itaukei / indigenous is no coincidence but very much related to commonalities in lifestyle risk we carry in a post-colonial nation.

?The future projectional forecasts remain a stern warning to consider immediate remodeling of strategies in health literacy on one hand and managing commercial determinants of health on the other. Behavior modifications once restructured and enforced will the crowning center piece.?????

Reference

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?18.??Mialon, M. Sharma, N. Sweetened and Sugary Beverages, NCD and Limits of Regulation pg. 39-44. The Governance and Ethics of Interaction. Lessons from Research, Policy and Practice. Case 3. Public Health and the Food and Drinks Industry:?UK Health Forum 2018 SSB Limits of Self-Regulation

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?Orchid number: 0000-0002-3192-2791

?Dr. Neil Sharma: [email protected] : Suva, Fiji