Small island states in crisis: the economic impact of lifestyle diseases in the South Pacific.
Public health concerns in the South Pacific region in recent years have shifted from the prevention and control of infectious diseases to dealing with the increasingly prevalent problem of non-communicable disease (NCD) or what has been termed lifestyle illnesses. Improved living standards have resulted in increased consumption of high fat diets and increased use of alcohol and tobacco. Epidemiological research has firmly established a relationship between these consequences of higher living standards and ill health. (2)
Foremost among these illnesses is diabetes which affects upwards of 30 million people in the Western Pacific region with predictions of this number doubling over the next twenty years. (3) Diabetes has become much more prevalent in the Pacific region with certain island nations reporting extraordinarily high population levels.
Nauru has one of the highest incidences of diabetes in the world with between 30 and 40 percent of the adult population suffering from the disease. (4) Hypertension and other circulatory diseases are also on the rise as the result of the adoption of modern diets high in saturated fats and oils and processed sugar rather than reliance on traditional root crops and fish as sources of carbohydrates and protein.
In Fiji, mortality rates and complications related to diabetes have significantly increased over the past thirty years with mean rates doubling about every five years. (5) In a comprehensive survey to measure the incidence of diabetes in the population of Fiji, Hoskins, et al (6) surveyed 5000 adults and found 24 percent of Fijian females and 15 percent of Fijian males to be diabetic while 34 percent of Indo-Fijian females and 25 percent of Indo-Fijian males were similarly identified.
The issue is both pertinent and topical. Pacific health ministers meeting in March 2003 in Nuku'alofa, Tonga heard of the gravity of the problem of lifestyle diseases from officials of the World Health Organization (WHO) and the Secretariat of the Pacific Community (SPC). (7)
Disease incidence is occurring in younger population strata, which restricts the ability of the stricken individual to contribute to the economic well being of his family. The impact on families that have lost a member to premature or sudden death from these types of illnesses is often severe. Community support structures rarely fully compensate for the loss of an economically active family member. These losses can and often do result in the impoverishment of families, restricting the ability to support children's education, and ultimately resulting in a cycle of poverty that is difficult to break. (8) In a larger sense, earlier disease onset impedes the ability of a developing country to exploit the energies and talents of a segment of the population that normally is the most dynamic contributor to economic growth.
Most of the research dealing with lifestyle disease in the Pacific region has attempted to categorize the types of illnesses that afflict the region and to quantify the number of individuals affected by the various maladies. The United Nations Development Program has been active in determining the scope of the problem. (9) The WHO and the SPC have reported on the problems of obesity in the Pacific, which arguably lies at the heart of the lifestyle diseases problem. (10) Dalton and Crowley attempted to estimate the costs to government of treating NCDs relative to overall spending for healthcare in Fiji, Samoa, and Tonga. Their findings indicate that between 40 percent (Fiji) and 60 percent (Tonga) of government spending directed toward healthcare and maintenance go to the treatment of NCDs. (11)
Beyond the estimation of explicit costs to governments of treating NCDs there has been no work done in the Pacific region that attempts to include an estimation of the economic impact of NCDs at the macroeconomic level. Specifically, how and to what extent this increase in NCD incidence places a drag on the economic growth potential of many Pacific Island nations.
Our intention was to monetize the annual economic loss suffered in our target nations as a result of NCDs. High rates of NCDs are a heavy burden on government finances, as many countries in the region will either partially cover (Fiji), or more commonly, fully cover (Nauru) the expenses associated with treating NCDs. These explicit costs are budget items and though an important factor in the capital budgets of these nations, are not the subject of our work.
More importantly for us is the effect these illnesses have on the productive lives of the people affected and thereby the economic potential of their nations. As mentioned, many people affected by NCDs in the Pacific are relatively young and in their prime productive years. Hours and days lost from work due to illness, either being too ill to work or the time taken in seeking treatment for the effects of their disease or diseases diminishes their ability to contribute to the financial support of their families and communities.
At a microeconomic level these impacts have serious consequences on the ability of the family to support itself at some socially acceptable level. This is especially true if the illness results in permanent disability and the withdrawal by the individual completely from the labor force. For example, many diabetics are prone to circulatory and nervous system damage as a consequence of their disease which may result in amputation of a foot or leg rendering the individual incapable of carrying out physical labor. While a very serious problem to the individuals and families affected, the problem is compounded when a significant portion of the population is afflicted with the same type of debility. Our interest is in monetizing and aggregating these types of individual debilities and costs through lost work time to provide a dollar estimate of the loss NCDs cause on the economies of the two nations we have chosen to study.
Economic development efforts in the developing world typically focus on building infrastructure, or institutional capacity, or promoting "good governance". Sufficient regard to, and promotion of, healthy life-styles are necessary antecedents for developing nations aspiring to maintain sustainable growth. Developing nations neglect effective preventative health programs at the risk of more than debilitated and marginalized segments of their populations; they risk retarding economic growth.
B. Research Approach
The survey portion of this project was conducted in two stages. The first stage occurred on Nauru in June, 2003. The second stage took place in Fiji in June 2004 at five different survey locations including urban, peri-urban, and rural health center environments. Initially we obtained permission from the Ministry of Health of Nauru to conduct a survey during June, 2003 among people being treated for NCDs at the central hospital serving the island nation. The survey targeted those individuals that suffered from diabetes, hypertension, cardiovascular disease, kidney disease, eye disease, and nerve damage. We chose Nauru and Fiji because of the high incidence of premature mortality for both men and women as a result of lifestyle disease. Approximately 20 percent of male Nauruans and 15 percent of females, die due to non-communicable diseases before they reach the age of 40.12 Nauru has the dubious distinction of having one of the highest rates of adult-onset diabetes in the world. In Fiji, life expectancy at birth has been stagnant for the past two decades even though infant mortality has been decreasing indicating higher adult mortality. (13)
The following narratives describe the research process at each of the survey locations.
Nauru--The Republic of Nauru (RON) Hospital's dialysis clinic treats approximately 10 patients per day in four-hour dialysis sessions three days per week. We visited the clinic on four consecutive days to be assured of including in our survey all individuals that visited the clinic during a normal week. We chose this venue and these individuals because most of these patients continued to be economically active (i.e. employed in the formal sector) in spite of the seriousness of their health problems.
In addition, student enumerators contacted individuals in their community districts that were known to have NCDs. These two sample sub-populations provided a total of 61 responses which represents 1.7 percent of the total population of interest.
Fij--We initially visited the diabetic and hypertension clinics being conducted at the Colonial and War Memorial Hospital (CWM) in Suva, the largest and most sophisticated medical facility in Fiji. Suva, Fiji's capital city, which is located on the island of Viti Levu, the Fiji archipelago's largest land mass. Over a period of two days eighty-two outpatients were interviewed.
The following two days were spent at the Valelevu Medical Clinic, which is located approximately fifteen kilometers from the Suva city centre along the densely populated principal arterial thoroughfare connecting the urban sprawl of Suva and the town of Nausori. The enumerators interviewed 69 outpatients waiting for consultation and treatment. In addition, the survey team conducted interviews at the Raiwaqa medical and diabetic clinic in Raiwaqa, a relatively poor section in the metropolitan Suva area.
The final urban survey locale was the Lautoka Hospital in the city of Lautoka on the western side of Viti Levu approximately 230 kilometers from Suva. The Suva survey team spoke to fifty outpatients at the general medical and diabetic clinics. The rural population of Fiji was sampled on Vanua Levu, Fiji's second largest island. We visited the Labasa Hospital in the town of Labasa. Our visits coincided with the weekly outpatient diabetic and hypertension clinics. A total of 308 usable questionnaires were completed during the Fiji portion of our survey work.
There is no other way than the survey method to collect these type of data in the developing world short of invasive procedures requiring medical teams engaging in complete physical assays including blood sampling, extensive medical history workups, and similar methods. This is a very expensive proposition better left to the individuals of the World Health Organization or research teams working with WHO funding. Our methods of asking straightforward questions of chronically ill individuals elicited what we feel were honest responses from people who were not told in advance of our site visits. We acknowledge that their responses may contain a significant margin of error but feel that the results are valuable as a first approximation of the magnitude of the problem in that region of the developing world.
Table 1 provides demographic information for the sample populations. The sample populations have been chosen expressly to reflect the impact of illness on the economic prospects of each nation and do not reflect the overall mean population demographics. The Body Mass Index (BMI) for the sample populations reflect the higher incidence of overweight individuals seeking treatment for NCDs. Obesity is a contributing factor to many of the NCDs experienced by peoples in the Pacific. Many Pacific Island nations have recognized the serious public health problem that obesity poses and have begun to implement educational programs to address the issue. However, it is thought that both a genetic predisposition to store fat and the movement away from traditional diets to modern manufactured foods heavy in fats and sugars as populations move from rural to urban areas are counteracting any positive impact that educational programs to modify diet and lifestyle may be having.
The sample populations are heavy relative to their short stature with the Nauruan sample registering in the obese BMI classification. The Fiji sample population less so though the BMI index for the Fiji sample is in the overweight category. The Nauruan sample is relatively well educated for a nation considered to be among the poorer in the Pacific. The sample populations in Fiji report fewer years in school.
2. Health (Alcohol-Tobacco)
Table 2 demonstrates that many of the individuals included in the sample populations indulge in either the consumption of alcohol or tobacco, or in many instances both. However, significantly fewer people in the Fiji sample smoked cigarettes which may be due to diligent anti-smoking campaigns that have been promoted by the government of Fiji. Most respondents reported being advised by a physician or other health care provider to quit or cut down on either alcohol or cigarette consumption or both. And most respondents reported in unstructured sample responses that following this type of advice was difficult considering the problems they faced in their daily lives and the need have a physical and psychological outlet to help them cope.
3. Health (Diabetes)
We chose our sample populations carefully to include large percentages of individuals afflicted with diabetes and other NCDs (Table 3). While the overall population of Nauru contains between 30 percent and 40 percent diabetic individuals depending on gender (females being more prone to the disease than males) our sample population contains a much higher percentage. Our Fiji data include fewer diabetics reflecting the greater number of general medical clinics we visited which dealt with various medical problems.
The impact of diabetes is severe in Nauru. The government of Nauru provides complete medical coverage for people being treated for the disease including medication, hemodialysis for those individuals suffering from kidney failure, and when financial conditions permit, the costs of kidney transplant which involves evacuation to and hospitalization in Australia. The ability of the government to continue this degree of beneficence is now limited due to the near exhaustion of the phosphate deposits which were the only source of export earnings for the island nation. A number of respondents mentioned that they had been waiting in some cases years for a transplant operation but the government did not have the funds. It appears from these data that the problem will not be solved anytime soon. More than 80 percent of Nauruan respondents reported that other family members were also diabetic.
4. Health--Heart, Kidney, and Eye Diseases
Significant portions of our sample population were afflicted with other types of NCDs in addition to or other than diabetes (table 4). The Nauru data reflect our visits to the dialysis clinic at the RON Hospital. One third of all respondents suffered from kidney disease. Many of these people were in end-stage renal failure and undergoing dialysis treatments with the expectation of receiving a kidney transplant in the near future if government finances permitted. A smaller percentage of the Fiji respondents suffered from kidney disease. There are no hemodialysis facilities in Fiji. The data describing kidney disease in Fiji probably reflect a combination of two factors; 1) lower incidence of diabetes, which is a strong contributing factor to renal disease; and, 2) a high mortality rate among people developing kidney disease and the inability to effectively treat renal failure without access to hemodialysis equipment. Kidney disease is a significant cause of lost work days due to illness. Those afflicted with kidney disease reported losing 48 days of work due to the debilitating effects of their disease. This includes the time spent in dialysis for those suffering from renal failure. Dialysis sessions require the individual to spend a minimum of four hours per session three days a week. More if problems arise in transport to the clinic or in hospital preparedness.
Diseases of the eye were the most common reported health problem by the sample populations. More than half of Nauruans sampled reported eye problems. The figure was thirty percent in the Fiji sample . This result is not surprising in the Nauru sample as diabetes also affects the delicate vascular system that nourishes the eye. Relatively high eye disease rates among Fiji residents may have to do more with the hot and dry climate of the western and northern regions of Fiji which contribute to the debilitating effects of diabetes on the eye. Arid climates dry the mucous membranes in the eye and provide an environment for opportunistic infections. However, in no nation was this source of illness an important contributing factor to work absence.
5. Health--Hypertension and Nerve Disorders
Table 5 (see next page) reports data on other NCDs that affected the sample populations. All groups reported significant levels of hypertension. Hypertension contributed to significant levels of lost productivity in all sample populations. In addition, nerve disorders were a relatively common complaint expressed by all sample populations affecting more than a quarter of the individuals in the Nauru sample.
6. The Macroeconomic Effects
Our objective was to monetize the dollar loss to each nation's economy from the acute and chronic effects of NCDs among the economically active members of the population. Our approach and objective omits those not in the labor force. While the debilitating effects of these diseases are as severe on those not in some type of formal employment as it is to those working for wages, attempting to estimate the financial impact on those outside formal employment with much confidence is a much more difficult and subjective task.
6a. Estimation Procedure
Data describing the incidence of select NCDs in the populations of Nauru and Fiji are available from SPC publications. (14) When different incidence rates were reported for males and females in each country we took a weighted average with 50% being the weight assigned to each gender specific rate. For instance, according to Coyne, the incidence of diabetes in Nauruan females is approximately 33 percent according to the latest survey data. The corresponding incidence figure for males in the population is 28 percent. Therefore the weighted average of diabetes incidence in the overall population is 30.5 percent. The average daily wage among those employed in the formal sector on Nauru is the equivalent of US$35.34. By knowing what percentage of the overall population suffers from a particular NCD and also what percentage of our sample population lost a given amount of work days to their illness, we determined what part of the overall population lost a similar number of days to the same illness.
Most individuals we interviewed suffered from multiple illnesses related to either their diabetic condition or some other chronic illness. We asked respondents to attempt to ascribe to each illness that they were afflicted with, a distinct number of work days lost. For instance, if someone suffered from both heart and kidney disease, we asked the individual to estimate the unique number of work days lost because of the affects of his heart disease, and the unique number of work days lost because of the effects of his heart condition. In this way we attempted to avoid the possibility of double counting days lost from work.
We determined the percentage of the population that is active in the labor force and the overall level of unemployment from U.S. Central Intelligence Agency data.. (15) When the number of people in the labor force was not explicitly provided, we took as the labor force those between the ages of 15 and 64 and factored out the reported level of unemployment. The number of people in the labor force times the number of people in the total working age population that lose the mean number of days to a particular illness gives the total number of people in the working population that lose the reported average number of days to an illness. The number of days lost times the average formal wage per day times the average number of people experiencing this loss provides the total loss in dollar terms to those employed in the formal sector.
1. Diabetes--Because of the widespread incidence of adult onset diabetes on Nauru and the fact that diabetes is a precursor to many of the other NCD illnesses of interest, the survey instrument did not directly solicit estimates of lost work time and productivity due to this illness. We wanted to avoid the risk of double counting productivity loss. Productivity loss is therefore measured as associated with the other NCDs, to which diabetes is a significant contributing factor, or results from the progression of the disease.
2. Heart Disease--Ten of 61 respondents in our sample population reported being diagnosed with heart disease. Six of those individuals reported losing an average of 32 days per year due to their condition including time lost from work seeking treatment, time in hospital, and feeling too ill to do their job.
3. Kidney Disease--Twenty of 61 respondents had kidney disease, many of those in end stage renal failure. Surprisingly, a majority continued to work in spite of the seriousness of their medical condition. However, the productivity loss was particularly evident among these people as they spent an average of four hours per day three days per week attached to a hemodialysis machine. Some were compensated by their employers for the time spent during dialysis and some were not. However, whether employees are compensated for their time away from work or not, the loss of their productivity is a real loss to the growth prospects and potential of Nauru. The average days lost during the past year resulting from kidney disease including treatment and debilitating effects of the illness was 48 days.
4. Eye Disease--Thirty two of 61 respondents had diseases of the eye. Eye disease is a common result of the progression of diabetes as the disease attacks the vascular structures in the eye and gradually causes blindness. Fifteen of the sample respondents reported losing an average of 10.8 days in the previous year due to eye problems.
5. Hypertension--Fifty four of 61 persons in the sample population reported having been diagnosed with hypertension. Thirty one respondents reported losing an average of 21.5 days of work over the past year because of the effects of hypertension.
6. Nerve Damage (neuropathy)--Sixteen individuals in the sample reported having been diagnosed with nerve damage, most generally to the extremities, which is a common affliction among diabetics. Eight individuals reported losing an average of 13 days of work in the previous year because of problems related to neuropathy.
7. Nauru Macroeconomic Impacts
Table 6 displays the projected estimates of overall dollar loss to the formal economy of Nauru from the NCDs included in the study.
The GDP of Nauru in 2004 in current dollar terms was US$25.4 million which includes US$24.4 million from the government of Australia in the form of payments to the government of Nauru to house refugees from the Middle East and Southeast Asia that have attempted to enter Australia illegally. (16) The drag on the overall economy as a result of lost work time due to the treatment, hospitalization and debilitating effects of NCDs amounted to approximately 14 percent of 2004 GDP or a loss of US$581 per capita for each member of the workforce. No current projections exist for GDP growth on Nauru. The tenuous state of the economy with its reliance on an essentially depleted stock of phosphate as its principal foreign exchange earner makes future economic viability dubious. But whatever future resource prospects, the deteriorating state of public health among the island's population bodes ill for any revitalization of the Nauruan economy and for the social and physical welfare of its people.
1. Diabetes--The incidence of diabetes in our surveyed sample was 52.8 percent of the 308 respondents. However, we assume an overall population incidence of 15 percent aggregating the indigenous Fijian and Indo-Fijian segments into one group. Further, the five Fiji survey sites (CWM, Raiwaqa, Valelevu, Lautoka, and Labasa) were merged into one dataset with weighted averages used to determine overall incidence and disease impact, the weights based on the number of observations taken at each site.
2. Heart Disease--our results indicate that 79 of 308 individuals in our survey reported being diagnosed with heart disease. Sixty-eight of these respondents reported losing an average of 33.8 days of work the previous year due to the effects of their illness including days involving hospital or clinic visits and instances in which the respondents felt too ill to work.
3. Kidney Disease--approximately 5 percent of the population of Fiji suffers from sort of kidney ailment . Sixteen people in our survey sample reported losing 16.2 days of work during the previous year due to kidney disease. In spite of the relatively advanced state of public health delivery in many areas of Fiji compared with other nations in the region, the effective management of kidney disease varies greatly according to geographic location and financial means. The Labasa Hospital on Vanua Levu has no kidney dialysis facility. Kidney disease patients in need of dialysis and without the means to secure overseas treatment usually succumb to their illness.
4. Eye Disease--we estimated that 5 percent of the population of Fiji is afflicted with diseases of the eye, many related to diabetic complications. In our survey 74 of 308 respondents reported losing 11.3 days of work during the previous year due to these conditions.
5. Hypertension--A large majority of survey participants reported being diagnosed with hypertension. Two hundred and thirty four of 308 people reported suffering from the effects of elevated blood pressure. Of these, 213 reported losing an average of 17 days of work in the previous year because of the effects of this condition.
6. Nerve damage -A total of 21 respondents reported this condition with 17 people indicating a mean loss of 10.8 work days during the previous year from its effects.
7. Fiji Macroeconomic Effects
Table 7 provides the estimates of overall dollar loss to the formal economy of Fiji in the previous year due to lost work time and subsequent lost income. The GDP of Fiji in 2005 was approximately US$1.9 billion.17 Our estimates indicate a loss to the revenue generating capacity of the labor force of US$26.9 million or approximately 1.4 percent of GDP. This figure should be taken as a minimum value since the loss in national income would have negative multiplier effects in the overall economy which we have not attempted to quantify.
The Pacific region has seen an increase in the incidence of NCDs as infectious disease has become less common and as the relative wealth of most of the region has improved. The burden of these illnesses is both financial to the individuals afflicted through lost productivity, and emotional, through the pain and suffering caused. The financial impacts are also severe and mounting for the governments involved due to the significant costs of disease treatment. The cost of managing lifestyle-related NCDs in the Pacific accounts for about half of health care expenditures in some Pacific island countries. Our work has assigned dollar values to the productivity and income losses experienced by those in the overall population that are economically active in the formal sector. Our estimates are undervalued probably by a number of orders of magnitude. They are admittedly and necessarily so because of the difficulties in accurately estimating physical debility due to disease in populations that are essentially rural where most economic activity occurs in the informal sector. However, our estimates provide a first approximation of the losses to the formal sector in these two nations as a result of NCDs. In that light they offer individuals involved in health policy formulation, information and insight to guide the budgetary and policy process to more effectively target these increasingly menacing afflictions.
(1.) The authors would like to thank the University of the South Pacific University Research Committee for their generous financial support which allowed us to undertake the research. We also are indebted to the Ministries of Health in Nauru and Fiji for their sanctioning of our field work allowing the research team access to rural and urban clinics and hospitals. Our gratitude also goes to the physicians, nurses and other medical staff in each island nation that worked with us during the survey process. Finally, we dedicate this work to the noble people who we met and spoke with that were being treated at the medical facilities we visited that carry on with their lives with exuberance and vitality in spite of the health problems and issues they face. We hope that the policy impact of this work does in some way positively affect their lives.
(2.) D. Kromhout, A. Menotti and H. Blackburn. Prevention of Coronary Heart Disease. Diet, Lifestyle, and Risk Factors in the Seven Countries Study. (New York: Kluwer Academic Publishers, 2002.)
(3.) World Health Organization. Plan of Action for the Western Pacific Declaration on Diabetes 2002-2005, (Manila, WHO, Western Pacific regional office. 2001.)
(4.) T. Coyne. Lifestyle Diseases in Pacific Communties. Secretariet of the Pacific Community. (Noumea, New Caledonia. 2000.)
(6.) P. Hoskins, D. Handelsman, and Hannelly, et al. 'Glycosylated hemoglobin as an index of the prevalence and severity of diabetes in bi-ethnic Fiji." Diabetes Research and Clinical Practice, 1987, 3:257-67.
(7.) Secretariat of the Pacific Community. Diet, Physical Activity, and Health. Meeting of the Ministers of Health of the Pacific Island countries. Nuku'alofa, Tonga. Available from URL: http//www.fiji.gov.fj/press/ 2003_03_17-03.shtml). Accessed September 2004.
(8.) United Nations Development Program (UNDP). Pacific Human Development Report 1999; Creating Opportunities, (Suva, Fiji. 1999.)
(10.) World Health Organization/Secretariat of the Pacific Community. Obesity in the Pacific; Too Big to Ignore. Report on a Workshop on Obesity Prevention and Control Strategies in the Pacific, (Samoa. 2000.)
(11.) Andrew Dalton, and Steven Crowley. Economic "Impact of NCD in the Pacific Islands" (with special reference to obesity). Paper presented at the workshop on Obesity Prevention and Control Strategies in the Pacific. Apia, Samoa, September, 2000.
(12.) Secretariat of the Pacific Community (SPC). Demographic Program. 1999.
(13.) United Nations Development Program (UNDP). Pacific Human Development Report 1999; Creating Opportunities, (Suva, Fiji. 1999.)
(14.) T. Coyne. Lifestyle Diseases in Pacific Communties. Secretariet of the Pacific Community.
(15.) Central Intelligence Agency (CIA) World Factbook, 2005. available from URL: http://www.cia.gov/cia/publications/factbook/geos/html. Accessed May, 2005.
(16.) U.S. Department of State. Available from URL: http//www.state.gov/r/pa/ei/bgn/16447.htm#econ. Accessed May 2005.
(17.) Central Intelligence Agency (CIA) World Factbook, 2005. available from URL: http//www.state.gov/cia/publications/factbook/ geos/fj.html#Econ. Accessed September 2006.
Philip Szmedra and K.L. Sharma/Small Island States in Crisis: The Economic Impact of Lifestyle Diseases in the South Pacific
* Philip Szmedra is Associate Processor of Economics, Georgia Southwestern State University, Americus, Georgia, 31709; and K. L. Sharma is Senior Lecturer, Department of Economics, University of the South Pacific, Suva, Fiji.
Table 1. Select demographics of the Fiji and Nauru sample populations Demographics Fihi * Nauru Age (mean) 54.1 42.6 Weight (kg) 74.2 86.2 Height (cm) 167.7 163.1 BMI ** 26.6 32.4 Number in family 4.4 5.0 Years in school 7.0 11.4 Married ((%) 90.0 60.7 Single (%) 5.2 26.2 Married years 30.8 18.3 * weighted averages by number of respondents at each sampled site. ** Body Mass Index--Below 18.5 = underweight 18.5-24.9 = normal 25.0-29.9 = overweight 30.0 and above = obese Table 2. Health impacts (Alcohol-Tobacco) in sample populations in Fiji and Nauru Trait Fiji Nauru Drink alcohol (%) 34.5 47.5 Smoke cigarettes (%) 16.5 40.0 Cigarettes per day (#) 15.3 30.7 Table 3. Health Impacts (Diabetes) in sample populations in Fiji and Nauru Trait Fiji Nauru Diabetic (%) 52.8 73.3 Time since diagnosis (yrs) 6.0 12.0 Times to clinic (per month) 3.3 5.5 Treatment (%): Diet 18.7 40.9 Insulin 17.2 15.9 Drugs 29.1 43.2 Diabetics in your family (%) 18.0 81.7 Table 4. Health Impacts (Other NCDs) in sample populations in Fiji and Nauru Trait Fiji Nauru Heart disease (5) 26.7 16.4 HD (days missed work) 26.5 32.0 Kidney disease (%) 7.7 32.8 KD (days missed work) 16.2 48.3 Eye Disease 28.7 52.5 ED (days missed work) 11.3 10.8 Table 5. Health Impacts (Hypertension and Nerve Disorders) in sample populations in Fiji and Nauru Trait Fiji Nauru Hypertension (%) 77.2 77.8 HYP (days missed work) 17.0 21.5 Nerve disorders (%) 10.9 26.2 Nerve (days missed work) 10.6 13.0 Table 6. NCD Economic Impacts to Nauru NCD Estimated Dollar Loss (US$) Heart Disease $312,198 Kidney Disease 2,523,148 Hypertension 200,147 Eye Disease 133,620 Nerve Damage 172,744 Total $3,341,857 Table 7. NCD Economic Impacts to Fiji NCD Estimated Dollar Loss (US$) Heart Disease $15,570,000 Kidney Disease 2,313,964 Hypertension 5,524,233 Eye Disease 1,856,171 Nerve Damage 1,581,209 Total $26,845,577