The impact of the environment on health and the health consequences of global warming are issues that have become increasingly prominent in political and policy debates in Australia, New Zealand and the United States.

These issues play out with even greater economic and social consequences in the developing countries of the Pacific Ocean, where fragile environments, failing economies, poor population health and a shortage of needed workforce skills mean there are fewer resources to prevent and manage them.

Rapid population growth, limited natural resources, and the effects of natural disasters such as cyclones and floods have driven many people to migrate from smaller outer islands to larger islands and from rural areas to towns, especially capital cities, looking for employment and public services. Others migrate internationally, and remittances are traditionally very important for Pacific Island economies such as Tonga and Samoa where they account for over a quarter for GDP.

While the numbers of people in the Pacific Island countries served with some form of improved sanitation and drinking water has increased, barely 50 percent of the population has access to sanitation, and less than 20 percent of the population has access to drinking water piped to households. There have been times when drinking water supplies have run out on some islands. It is ironic that a popular and expensive brand of bottled water in Australia and the United States is from Fiji, where up to one-third of the population does not have access to safe, clean drinking water.

With increasing population growth and a decline in subsistence farming, the demand for food in the Pacific Islands is increasingly being met by imported food of poor quality and nutritional value. These changes in diet are contributing to the substantial and growing levels of overweight and obesity, and the cardiovascular diseases and diabetes which follow. Micronutrient deficiencies are also common in the region, leading to conditions such as anemia and goitre.

These lifestyle diseases have attacked the Pacific Island way of life over the past few decades. Seventy to eighty percent of premature Islander deaths are from preventable, non-communicable diseases.

The data are shocking: Tokelau, Nauru and American Samoa have gained the dubious crowns as the top three countries in the world with the highest percentage of obese people, with more than 93 percent of the population overweight or obese. In American Samoa, Tokelau and the Marshall Islands, more than 40 percent of adults aged 25 to 64 years old have diabetes. Unless action is taken, the number of diabetes cases is expected to double by 2025.

A major contributory factor here has been that most health expenditure on non-communicable diseases is for tertiary care, with very little funding available for prevention and primary care. The Pacific Islands have some of the highest expenditures on health for developing countries; a significant number of countries spend more than 10 percent of their GDP on health. Much of this is spent on sending patients to Australia, New Zealand and the Unites States for specialist treatment.

Many Pacific Island countries currently suffer high burdens from climate-sensitive health outcomes, including morbidity and mortality from extreme weather events and from vector, food and water borne diseases, and it is expected that these burdens will increase as a consequence of climate change.

For example, floods and droughts are each associated with an increased risk of diarrhoeal diseases and the rates of diseases such as malaria and dengue fever are increasing. The distribution and abundance of their disease vectors are affected by changes in ambient temperature, precipitation, vegetation and water availability. There is a positive correlation between the annual number of epidemics of dengue in the South Pacific and the Southern Oscillation Index, denoting El Niño conditions. Other increased health threats as a consequence of global warming include cholera outbreaks and an increased incidence of ciguatera poisoning from the consumption of reef fish.

It’s clear that tackling these problems will require some new approaches. Realistically these will be driven by Australia, New Zealand and the United States as the countries that have the biggest investments – trade, aid, national security and health – in the area, and also the strongest government and cultural ties.

The Pacific Islands are the most heavily aid-assisted part of the world on a per capita basis. But no-one – donors or recipients – gets real value under the current system. There is a plethora of plans for the Pacific Island nations, to the extent that efforts to implement all of these risk confusion, duplication and poorly directed spending. Although most countries have development strategies, these are not always implemented effectively and too often there are no accompanying financing plans.

The 2009 AusAID Annual Review of Development Effectiveness found two challenges for program management:

• A continuing proliferation of individual aid activities relative to overall funding, leading to a duplication of effort, insufficient investment and unsustainable outcomes; and
• A lack of clarity in program objectives, with many objectives not clearly linked to the desired outcomes.

It’s time for international leadership in better coordination of programs and efforts and increased capacity building in the Pacific Island nations. Tackling the social determinants of health is a good place to start.