Kiribati: Where the climate emergency and public health collide

The Pacific island nation of Kiribati is fascinating and beautiful but also troubled. It is a country on the frontline of the climate emergency.

Kiribati is the only country in the world to touch all four hemispheres. The 32 atolls and one coral island lie between Australia and Hawaii and collectively cover just 313 square miles of land in a vast 1.3 million square miles of ocean.

Some eastern islands take a week to reach by boat from the main island, and, if not for a quirk in the international date line, would be a full 24 hours behind.

It's here, in October 2022, that Médecins Sans Frontières / Doctors Without Borders (MSF) officially launched its first medical project in the equatorial island nation.

Half of Kiribati’s 120,000 people live in the capital, South Tarawa. The main island is a thin strip of land that can barely accommodate the population.

As a result of a brisk birth rate – 26 births per 1,000 people – and urbanisation due to migration from the outer islands, overcrowding in South Tarawa is exacerbating health and social problems, as well as environmental issues.

“Kiribati has one of the highest burdens of disease in the world,” says Alison Jones, MSF medical coordinator for Kiribati.

“[This] includes the highest incidence of leprosy, one of the highest of tuberculosis and diabetes; and some of the lowest access to primary healthcare. There are clear needs here that are not being met.”

On top of this, environmental issues are a significant and growing concern.

Food insecurity

One clear problem with shrinking land is the threat to agriculture. Although it has been declining in recent years, most i-Kiribati are subsistence farmers, especially on the outer islands.

Fishing has also been affected. Overpopulation, as well as the impact of climate change on reefs, means that coastal fisheries soon won’t be able to meet domestic food needs. 

Overall, it’s estimated that Kiribati will need 50 percent more food by 2023 to sustain itself.

Food insecurity is not only due to extreme weather. Lifestyles are changing, too. 

Many young people no longer produce and prepare food in traditional ways, while also preferring the convenience of imported foods. 

Fresh produce is also not widely accessible. A pumpkin can cost $20 USD and a watermelon $32. This is well out of reach for most people, considering minimum wages are around $1 per hour.

It is not surprising then, that almost all i-Kiribati people miss out on the recommended servings of fruit and veg.

A move away from traditional diets of fish, babai (swamp taro), breadfruit, coconuts, and pork for special celebrations has implications for people’s health. The majority of people now eat white rice as a staple, with the addition of imported sugary drinks, and canned and processed foods. 

It’s estimated that 38 percent of men and 54 percent of women are obese, while among children under age five, 25 percent are underweight. 

When it comes to the risk factors associated with developing chronic diseases – known as non-communicable diseases or NCDs – 70 percent of adults aged 18-69 have three or more symptoms. NCDs are often life-long illnesses and include conditions such as heart disease, diabetes and asthma.

Climate and chronic disease

Human health is dependent on the health and sustainability of the environment. Nowhere is this more evident than for people living within the constraints of an island.

“Here you see the collision of planetary health and NCDs that is unseen anywhere else,” says Dr Lachlan McIver, MSF tropical diseases and planetary health advisor. 

McIver calls small island states like Kiribati the “canaries in the coal mine of climate change”.

Around 75 percent of deaths in the Pacific region are due to NCDs, which are now recognised as the leading cause of health problems in Kiribati.

In addition to a poor-quality diet, hypertension, lack of exercise and smoking contribute to these high rates of disease. In particular, the diabetes rate in Kiribati is high and increasing. Among women aged 45-69, more than 44 percent have diabetes.

“Diabetes in pregnant women is of particular concern as the condition can be high risk for mums and babies who then require access to specialist care during labour, delivery, and after birth,” says MSF midwife Sandra Sedlmaier-Ouattara.

Maternal health

MSF’s new project in Kiribati aims initially to improve the detection and treatment of NCDs related to maternal health. The work is focused on the Southern Gilbert Islands and is based in Tabiteuea North.

Currently, any high-risk pregnant women on the outer islands have limited access to specialist care and must leave their families behind to be flown to the capital Tarawa for support until they give birth and after if needed.

“Our activities in local health clinics include improving antenatal care in general, with an additional focus on the early detection of diabetes and hypertension. We also support delivery and neonatal care at the Southern Kiribati Hospital,” says Sandra.

“To have long-term impact and for sustainability, our activities are focused on training and mentoring our local midwife, nurse, and doctor colleagues.”

Other activities in Tabiteuea North and Tarawa include working to improve newborn care in the first 24 hours of life through training midwives, nurses and doctors in the universally recognised Helping Babies Breathe programme.

MSF will also support hospital infrastructure upgrades at Tabiteuea North Hospital, such as providing renewable energy, clean water and waste management, as well as supporting referrals and surgical capacity.

The Pacific islands are among the most climate-vulnerable places on Earth, and Kiribati is showing the world some of the most tangible impacts of climate change yet. 

Here, we must act together for planetary health and all of human health.