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“A matter of life and death: ignoring ethnicity” (FT 1/2/2020)

01/02/2020

A matter of life and death: does ignoring ethnicity help Indo-Fijians? (FT 1/2/2020)


Professor Wadan Narsey

 

Note on ethnic terminology

In this article, I use the ethnic terms that the authors of the academic studies themselves used (for example in the graphs or quotes) rather than what I prefer to use:

I use “indigenous Fijians” and “Indo-Fijians”.
Fiji Times uses “I-Taukei” and “Fijians of Indian Descent”
And others studies use all and sundry, including “Indian”]

There is little doubt that the Bainimarama Government’s refusal to give statistics by ethnicity is due to their desire to eliminate racially discriminatory policies against Indo-Fijians.

Indeed, the progressive Bainimarama Government policies such as freeing up education for all Fiji citizens, regardless of race, and even calling everyone “Fijian” has no doubt won him the vast majority of Indo-Fijian votes in the last two elections.

But does calling everyone “Fijian” necessarily mean that Fiji’s official statistics produced by the Fiji Bureau of Statistics or any government ministry, must ignore ethnicity as a variable?

Indeed, does ignoring the ethnicity of Indo-Fijians statistically assist Government and NGOs to tackle problems which may be specific to Indo-Fijians?

I suggest in this article that the Bainimarama Government’s refusal to present statistics by ethnicity is undermining Government, NGOs and the Indo-Fijian community itself from understanding and tackling the massive health problems Indo-Fijians face as an ethnic community.

Erudite lawyer Richard Naidu recently tweeted in support of my last week’s FT article (paraphrasing slightly) “if we don’t measure, we cannot manage”.

In this article I give two examples where not measuring ethnicity is potentially harming the welfare of Indo-Fijians and reducing the capacity of policy makers to act in their interest.

The first example is derived from the analysis of Fiji’s NCDs health problem by the 2011 STEPS Report, and the second is from a paper by health researchers which has some findings which are contrary to that of the 2011 STEPS Report.

Many gems in the 2011 STEPS Report

The Fiji Government’s Ministry of Health and Medical Services and WHO (Western Pacific Region) did a solid national survey in 2011 and published the (undated) 2011 STEPS Report on Fiji’s NCD Risk Factors.

The authors were Dr. Wendy Snowman, Dr. Ilisapeci Kubuabola and Dr. Isimeli Tukana, with a host of other local contributors (read the anonymous “Acknowledgement”).

In the foreword, the MOH Minister, Hon. Jone Usamate (my former student at USP) in acknowledging the partnership of the collaborating organizations, emphasized that “it creates evidence to inform strategic interventions to Fiji’s NCD Crisis”.

Indeed, the 2011 STEPS Report is a treasure trove of statistical “evidence” that can help policy makers in Fiji towards “strategic interventions” of targeted policy responses where they matter.

The Executive Summary by the authors noted that their objectives were not just to document the prevalence of key NCDs but “better understand the major modifiable risk factors for common NCDs. These include physical inactivity, poor diet, obesity, high blood cholesterol and lipids, tobacco, alcohol and kava abuse” AND “to study and compare NCD and its risk factors across different strata of age, gender and ethnicity”.  Note the inclusion of “ethnicity” as an important factor.

But official statistics today ignore ethnicity.

Problem areas for Indo-Fijians

The 2011 STEPS Report has dozens of conclusions where ethnicity are crucial factors (and often critically allied to gender).

I suggest that academics, senior students and even good journalist can write dozens of fascinating “stories” to explore in this Report, if only they take the time to see the “forests” behind the masses of “trees” of statistics.

Let me just focus on a few conclusions affecting Indo-Fijians adversely, based on some very sound statistics:

* Indo-Fijians were less active than i-Taukei

* far more Indo-Fijian men engaged in “binge drinking” than iTaukei men.

And more to do with this article,

* mean fasting blood glucose levels were higher for Indo-Fijians than i-Taukei

* there was more diabetes amongs Indo-Fijians than i-Taukei

But there was one conclusion that continues a theme I discussed in my article last week, that of “obesity” of Fiji’s women and correlation with diabetes and other NCDs.

Bio Mass Index (BMI)

Health experts use the concept of “Bio Mass Index” (BMI) to establish whether people are underweight, normal, overweight or obese.

The BMI is calculated as the weight of the person (kg) divided by their height squared (meters squared).

Of course, one expects taller people to be a bit heavier.

WHO recommendations then define the following standards:

Underweight:  BMI is less than 18.5 kg per meter squared

Normal:           BMI is between 18.5 and 25

Overweight:     BMI is between 25 and 30

Obese:             BMI is over 30.

Using these standards, the 2011 STEPS Report concluded that 41% of iTaukei were obese, compared to only 18% of Indo-Fijians.

This conclusion would seem to match common sense observations of Fiji people, doesn’t it?

But not all health experts think so.

It turns out that some expert medical researchers believe that it is not appropriate to use the same universal BMI standards to judge different ethnic groups as “obese”.

And they have sound statistical results that challenge the some of the obesity conclusions of the 2011 STEPS Report about indigenous Fijians being more obese than Indo-Fijians,  and indeed the opposite may be the case.

Contrary obesity findings by Taylor et al

Students might want to look for this fascinating academic paper “Diabetes and obesity trends in Fiji over 30 years” in the Journal of Diabetes (8 (2016), 533-543, based on a study funded by the Australian Government’s DFAT (freely available on the internet).

The authors were reputable health researchers led by Professor Richard Taylor (University of NSW) and others (Sophia Lin, Isimeli Tukana, Christine Linhart, Stephen Morrell, Penina Vatucawaqa, Diana Magliano and Paul Zimmet.) (hereafter referred to as Taylor and Others).

Fiji Times readers should note that two of these authors were Fijians, of whom one also contributed to the 2011 STEPS Report.

This 2016 paper examined the data on Type 2 Diabetes in Fiji going back for thirty years, to see if there were any trends over time and how this pernicious disease might be related to evidence on “obesity” of Fiji people.

They disaggregated by many variables, including age, urban/rural, type of employment, gender, and ethnicity.

Their task was immensely difficult because many previous surveys were not truly random national samples, the numbers in samples were often not large enough to make solid judgements, and definitions of what constituted diabetes was changing over time, to give just a few of the difficulties.

Nevertheless, after much sifting of data and statistical adjustment, they reached conclusions on prevalence and trends of Type 2 Diabetes that seemed quite clear.

To get the messages across, I focus on just i-Taukei women and Indian women (terms used by the academic researchers) but the picture is similar for the men.

The first big story is given by Graph 1 which I have derived from statistics in Table 3 of the research paper (all graphs are from selected statistics in that table).

Graph 1 shows that the incidence of Type 2 Diabetes has been steadily rising for thirty years.

The second big story from the same graph is that the incidence of Type 2 Diabetes has been roughly twice as high for Indian women as for i-Taukei women.

But when the researchers looked at one of the risk factors associated with diabetes, obesity, Graph 2 confirmed that obesity rates had indeed been steadily rising for thirty years, correlating with the rising Diabetes Type 2.

BUT the puzzling result was that according to the standard definition of obesity (Bio Mass Index greater than 30), the relativities were reversed: i-Taukei women were twice as obese as Indian women.

This of course was also the findings of the 2011 STEPS Report.

Taylor and his team then investigated whether their definition of “obesity” by the Bio Mass Index, needed to be “ethnic specific” and whether that would make a difference to the relativities in “obesity”.

Health experts now that while weight to height (squared) ratios are important risk factors in NCDs, so also is the amount of body fat in a particular weight of body.

It turns out that Pacific Islanders and Indo-Fijians (Asians) have different proportions of body fat compared to “Europids” (who we in Fiji refer to as “Europeans”).

Adjusting for fat content differences in different ethnic groups, some health experts assessed that

* the “ethnic specific BMI” standard for Pacific Islanders should be a higher 32 (kg per meter squared) (not 30) (to simplify, Samoans, Tongans and Fijians are “naturally big”) and

* the ethnic specific BMI standard for Indo-Fijians should be a lower 25 (kg per meter squared) (not 30) (in simple English, Asians are “naturally small” people).

From the data in the research paper by Taylor and others, I have derived Graph 3 which gives  Prevalence of Obesity of  i-Taukei and Indian women according to “ethnic specific BMI”.

Yes, there was the same rising trend of obesity over the thirty years.

BUT with “ethnic specific Bio Mass Index” to define obesity, the ethnic relativities were completely reversed and now matched the relativities and trends in prevalence of Diabetes Type 2 (Graph 1).

For every year the survey had been done, Indo-Fijian women were twice as obese as iTaukei women.

Moreover, even though the rate of obesity among iTaukei women in 2011 was a high 40%, that of Indian women was an astronomical 65%.

Shocking news indeed.

And clearly not just a result of diet differences between i-Taukei women and Indo-Fijian women.

A matter of life and death

Professor Taylor and his colleagues concluded that the rising rates of obesity will continue to drive the increasing incidence of Type 2 Diabetes and other NCD burdens of premature morbidity (diseases) and mortality (deaths).

This adverse conclusion applied especially to women because their risks of Diabetes is apparently higher than that of men at the same levels of obesity.

These health experts pointed out that in Fiji, Cardio Vascular Diseases have increased premature adult mortality (people “dying before their time”) and that “Fijian life expectancy has not improved since 1985 in both sexes and ethnicities”.

How shocking given that our GDP per capita has been steadily rising.

Some of us have been pointing this problem out for twenty years now: read my FT article of 21/2001 “Till death do us part: strange facts on life expectancies”.

Or read my FT Letter to the Editor of 31/10/2013 “Where are the 2007 Census Analytical Report” which letter was miraculously printed even by the Fiji Sun) asking many pertinent questions about Fiji’s stagnant life expectancies, and possibly falling for Indo-Fijian males.

But Professor Taylor and his colleagues, without presenting any evidence that I can see, are stating something more shocking that “The situation is worst in iTaukei women, for whom recent evidence indicates life expectancy has decreased”.

But surely the life expectancy of Indo-Fijian women, though currently higher than that of indigenous Fijian women, might also be falling?

So why is the Fiji Government withholding all statistics on ethnicity from the public?

Fiji Times readers might note that a recent Vital Statistics Report 2012-2017, supposedly compiled by FBS, MOH and the Registrar General’s Office, does not have a single indicator or table by ethnicity.

Yet the health experts quoted in this article (STEPS Report, Professor Taylor and others) clearly show that ethnicity is a profound factor  in NCDs, Diabetes Type 2, Cardiovascular Diseases, morbidity, mortality  and life expectancy.

The 2011 STEPS Report had looked forward to a similar survey and Report for 2019.  Was this ever done or is it being planned and with the same methodology as the 2011 STEPS Survey?

Note that Professor Taylor and his colleagues point out “Lack of long-term studies examining BMI and obesity-related mortality across ethnic groups has prevented these ethnic-specific cut-off points from being validated, recommended, or adopted more widely”.

It is an ongoing tragedy that Fiji’s health experts and demographers, both indigenous Fijian and Indo-Fijian, are nationally silent (whatever they may say privately) on the ongoing refusal by the Bainimarama Government to collect statistics by ethnicity.

Do they not know the facts?

Or do they not care?

Or is it just the culture of collective intellectual cowardice that seems to have gripped the nation’s intelligentsia?

What this article has tried to do is show that while the Bainimarama Government may wish to help Indo-Fijians with the slogan  “we are all Fijians”,  not collecting statistics by ethnicity is a matter of life and death for Indo-Fijians and indeed, all Fiji citizens.

[The next article addresses another massive problem facing Indo-Fijians particularly, which they ignore at their peril, even if the Government refuses to give them the relevant data.]

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