Critical medical ecological perspectives on diabetes in the Pacific Islands: colonialism, power, and balance in human-environment interaction over time

Abstract Background Diabetes is endemic in Pacific Island jurisdictions where complex colonial relationships arose from the Spanish Empire, Japanese and German occupation in World Wars 1 and 2, and the Pacific Trust Territory era of the USA. Since diabetes reflects a cluster of ecological processes involving sociobehavioural, medical, and environmental constructs, interpretation of the diabetes epidemic requires both an ecological and intervention framework with an economic and political perspective that accounts for historical and contemporary power relations. Methods We conducted qualitative interviews with 272 local residents (totalling 3440 h) of seven Pacific Island communities (Majuro, Pohnpei, Palau, Kayangel Atoll, Saipan, Tinian, and Rota). Interviews were recorded and an inductive analytical plan implemented (analysed for themes within and across sites). An ecological interpretive framework that situates humans within their bodily and environmental context—combined with historical socioeconomic power dynamics (and agency)—informed the generation of findings and implications. Findings Communities attribute diabetes in their islands to the direct result of rapid shifts in lifestyle brought from the Japanese (World War 2) and US (Trust Territory) periods of colonial history. The replacement of local starches with rice during the Japanese period, combined with the replacement of local protein sources with US canned meats, fish, and instant foods, catalysed a diabetogenic diet. Shifts in food economies replaced local forms of trade, barter, and reciprocity. Local forms of physical activity—procurement of local food (fishing, gardening)—became devalued in the new food environment, further creating metabolic disease. Individuals from more remote locales are more likely to see their way of life as healthier than their counterparts in central population hubs, and attribute this asset to the slower reach of development, the subsequent lower processed food consumption, greater engagement with traditionally meaningful local activities, and a stronger reliance on local medicine, with less access to Western medicine. Interpretation Island communities are aware of the dynamics historically that led to their present food and health environment. Cultural and community assets—perceived as resilience by community members—could be promoted to support social norms that contribute to growing local pride, traditional thinking and behaviours, and a redefinition of "healthy". Funding US Centers for Disease Control and Prevention Research Center Program.