Malnutrition in Kiribati

This article first appeared in The Lancet on 06 May 2023 .

In December, 2022, Joanne Clarke flew home to the UK for the Christmas holidays. She had been working in Australia where she was in the final stages of training as a paediatrician. One morning, during her break, she awoke to a multitude of texts and missed calls from a Médecins Sans Frontières (MSF) staffer who manages doctors' postings. The staffer informed her that there was an urgent need for a specialist paediatrician in the island nation of Kiribati, located in the Pacific Ocean, as the current one was leaving the country for another job.

“The first messages were ‘are you interested?’” Clarke remembers. “An hour later, the next message said: ‘I've put you forward.’” Clarke was bemused but intrigued. She had already spent time working with MSF in South Sudan and Afghanistan, and agreed to take the Kiribati post, thinking it would be an interesting change. However, once she arrived at Tungaru Central Hospital to begin her 5-month assignment there, she realised that the reality was much more complex.

Kiribati, made up of 32 atolls and one raised coral island situated between Australia and Hawaii, is one of the poorest countries in the Pacific region. Around half of the 120,000 population live in the overcrowded capital South Tarawa, where unsanitary conditions are common and tuberculosis is rife. Fertility rates in Kiribati are high, but it has one of the highest rates of neonatal mortality in the Pacific region (ie, 39 deaths per 1,000 livebirths, compared with 3 deaths per 1000 livebirths in Australia) and under 5 mortality (48 deaths per 1,000 children). Covering an immense area, mainly ocean, it also has one of the lowest rates of access to primary care in the world.

At the request of Kiribati's Ministry of Health and Medical Services, MSF stepped in to support maternal and neonatal health on the main island of Tarawa, as well as on the remote southern Gilbert Islands in October, 2022. Subsequently, in December, 2022, there was the call for specialist paediatric support. What surprised Clarke the most when she arrived, were the high numbers of severe acute malnutrition cases in children. “On one day last week, we had 12 patients in the paediatric ward, of which eight had severe acute malnutrition. I didn't expect it to that extent. This makes them really vulnerable to infections, then they become more malnourished because they're unwell. And it becomes a vicious cycle.”

Unicef says the rise in admissions and deaths compared with the previous year is very concerning. Nick Rice Chudeau, Chief of the Unicef Kiribati Office, said that 22 children have been admitted to hospital with malnutrition and six have died so far in 2023. “In a population of 120,000, that's a very high figure and we are only just in May”, he added. The latest Unicef figures indicate a prevalence of 1.3% for severe acute malnutrition and 2.2% for moderate acute malnutrition in children. Although these rates are low according to WHO definitions, malnutrition appears to be on the rise, Rice Chudeau says.

Clarke put malnutrition down to poor feeding practices; stopping breastfeeding too early; and using formula that is overly diluted, not giving enough feeds per day, or use of inappropriate milk. Unicef figures show that 90% of children in Kiribati live in food poverty. Only 8.3% of children aged 6–23 months receive the minimum acceptable diet according to Unicef's Multiple Indicator Cluster Survey 2018–19.

The impact of climate change on nutrition and health is all too visible in Kiribati. Drought has led to wells going dry and many others going brackish due to seeping seawater in the low-lying land. The highest point on Tarawa is just 3 metres above sea level and levels are rising. As a result, there is less land for crop use on the islands and much of the remaining soil is contaminated with salt or it is sandy and, therefore, more difficult to cultivate, contributing to food insecurity and rising prices.

Kiribati is estimated to need 50% more food by 2030 to sustain the growing domestic demand. With overcrowding and the shortage of clean water, there are increased cases of diarrhoea and skin infections such as scabies. Respiratory conditions such as pneumonia and bronchiolitis are common. In March, 2023, there were more than 100 paediatric hospital admissions and around 30 neonatal hospital admissions.

Rice Chudeau says the malnutrition cases are probably linked to the scarcity of safe drinking water. “It's sometimes difficult to make those connections”, he said, “but we're seeing that when people don't have a lot of water, they have to make very difficult choices on how they will use that water. What we're seeing is a lack of handwashing with soap at critical times, like before breastfeeding, after using the bathroom, and after cleaning a child before eating and we suspect that there could be a connection between the drought and the increase in malnutrition.”

Unicef is working with the Ministry of Health and Medical Services on several nutrition projects including strengthening nutrition screening and supporting extensive community outreach to raise awareness about good hygiene practices and has introduced multiple micronutrient powders and vitamin and mineral supplements.

Lachlan McIver, Tropical Diseases and Planetary Health Advisor at MSF headquarters in Geneva, says there is a catastrophic combination of risk, exposure, and health burden in Kiribati. “Climate change is not some distant future threat for the people of Kiribati or elsewhere in the Pacific. It's a daily reality which inevitably has an effect on one's mental health and sense of identity. People are already losing lives, land, and livelihoods due to climate change.” The fact that some of Kiribati's leaders are encouraging the population to consider voluntary out-migration is a sign of how grave the situation has become.

The problem for remote islands growing and retaining their own doctors is tricky as they have to go abroad—typically to larger islands such as Fiji and Papua New Guinea, or to Australia or New Zealand—for undergraduate and postgraduate training.

This means the local home population do not have the benefit of their skills for years, and many do not come back at all. For the ones that do return, there is an issue of them having the skills necessary to practice safely and sustainably in remote unsupervised settings in the outer islands of each state.

In a country with a high health burden and a relatively weak health-care system due to lack of funding, shortages of clinicians are acutely felt. In paediatrics, there had been two senior paediatricians in Kiribati, but one died and the other then left to work on another Pacific island. Clarke is supported by four local paediatric registrars and three interns.

Before joining MSF, McIver, a specialist in rural and remote medicine and public health, who has worked intermittently in the Pacific region for 15 years, co-founded the charity Rocketship Pacific to fill this gap. Since 2015, Rocketship has been working in partnership with Ministries of Health and other key partners, first in Timor-Leste, then the Solomon Islands, Fiji, Tonga, and Vanuatu to design and deliver postgraduate training programmes in the core generalist disciplines of family, community, and rural hospital medicine.

Since 2018, Tongan doctors training towards their diploma and master of Family Medicine degrees have been able to complete their studies while remaining living and working in Tonga—the first time such remotely supported in-country training had been made possible in the region. Additionally, experienced rural generalist volunteers in Australia and Fiji provided remote medical education and mentorship, combined with clinical teaching visits and assessments in Tonga. It was the only specialty training programme at Fiji National University to have been able to continue during the COVID-19 pandemic because of the way it was set up. McIver, a pro bono board director, says “COVID-19 effectively demonstrated the robustness and the value of the Rocketship model.”

To date, around 50 doctors have reached either their diploma or master's level Family Medicine degrees through Rocketship. Once qualified as masters, they are able to train the next generation of home-trained specialists. The model used in Tonga has now expanded to Vanuatu, and Kiribati is in discussion with Rocketship about enrolling an inaugural cohort as early as next year.

McIver hopes that in the not-too-distant future, Kiribati will no longer need support from organisations such as MSF or Rocketship. “Our strategic priority is to train the trainers”, said McIver. “I believe the aim for Kiribati, and the rest of the Pacific region, should be to have enough home-grown clinicians, equipped with the necessary skills, to provide quality health care for all people across the blue continent.”